Compendium of AoA FY 2010 Discretionary Grant Awards

U.S. Department of Health and Human Services 

U.S. Administration on Aging 

Compendium of AoA 

FY 2010 Discretionary 

Grant Awards 

Under Title IV of the Older Americans 

Act 

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Explanatory Notes 

The Administration on Aging (AoA) Compendium of FY2010 Grants is the 31 st edition of the 

annual compilation of project grant abstracts awarded under the Older Americans Act (OAA). 

It is in accordance with the OAA Section 432(b) which calls for the Assistant Secretary to 

submit a report to the U.S. Senate and House of Representatives which describe projects 

funded in the previous Fiscal Year. 

This compendium includes 428 project descriptions including 230 new awards and 198 

continuations. Readers will note the increased number of grants awarded by AoA funded 

with appropriations authorized by legislation other than the Older Americans Act. In 2010 

both formula and discretionary grants were awarded under the American Recovery and 

Reinvestment Act of 2009. New this year were grants funded under the 2010 Affordable 

Care Act. The Public Health Service Act and the Health Insurance Portability and 

Accountability Act of 1996 have supported grants under AoA’s Alzheimer’s Disease 

Supportive Services Program and Senior Medicare Patrol programs in the past. 

The major change in the appearance of this year’s edition is that project descriptions have 

been organized by the funding opportunity announcement in which applications were 

submitted and prefaced by a brief description of program or content area in which project 

awards were made in FY2010. Awards made to State government and tribal organizations 

under the Medicare Improvements for Patients and Providers Act (MIPPA) announcements 

were awarded on a non-competitive basis and were not required to submit full applications. 

Funds appropriated were allocated by formula. While they are not described individually, 

general descriptions of the awards are included. 

Last year the following changes were made and are continued in this edition: 1) Only new 

and continuation projects receiving FY2009 funds are included – previous editions included 

active projects which did not receive new funding; 2) Project descriptions are organized by 

the AoA organizational unit responsible for monitoring projects with the exception of 

Congressional directed awards which are administered throughout the agency; 3) the index in 

the back of the compendium is grouped by the type of grant organization and within each 

category organized by State; and 4) project descriptions include the name of the AoA project 

officer. 

Readers interested in learning about projects should first contact the grantee organization. 

The contact name and the AoA project officer are subject to change even during the course 

of the project period. Information about program areas can be found on the AoA website: 

http://www.aoa.gov and on websites of organizations serving as technical assistance 

resource centers that can be accessed through the AoA website. 

Telephone: (202) 619-0724 

Email: 

aoainfo@aoa.hhs.gov 

Mailing Address: U.S. Administration on Aging 

Washington, D.C. 20201 

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Table of Contents 

Explanatory Notes .................................................................................................................. i 

Table of Contents .................................................................................................................. ii 

Center for Planning, Policy, and Evaluation ....................................................................... 1 

Aging and Disability Resource Centers........................................................................... 2 

Aging and Disability Resource Centers – Expansion and Enhancement Projects............ 3 

Aging and Disability Centers - Options Counseling ........................................................ 52 

Aging and Disability Centers – Evidence Based Care Transition Programs................... 73 

Alzheimer’s Disease Supportive Services Program (ADSSP)...................................... 90 

Alzheimer’s Disease Supportive Services Program: Evidence-Based Programs .......... 91 

Alzheimer’s Disease Supportive Services Program: Innovation Projects .................... 103 

Chronic Disease Self-Management Program............................................................... 125 

Chronic Disease Self-Management Program State Grants .......................................... 126 

National Resource Center ............................................................................................ 174 

Community Living Program .......................................................................................... 176 

Community Living Program – State Projects................................................................ 177 

Community Living Program – Consumer Direction Technical Support......................... 194 

Evidence-Based Disease and Disability Prevention Program ................................... 196 

Evidence-Based Disease Prevention – State Programs .............................................. 197 

Evidence-Based Disease Prevention Programs – National Resource Center.............. 222 

Evidence-Based Disease Prevention Programs – Evaluation Design .......................... 225 

Next Generation - Performance Outcome Measurement Project (POMP)................. 227 

Center for Program Operations........................................................................................ 235 

Lifespan Respite Care Program.................................................................................... 236 

Community Innovations for Aging in Place................................................................. 251 

National Center for Benefits Outreach and Enrollment.............................................. 267 

Aging Network Improvements ...................................................................................... 269 

Lesbian, Gay, Bisexual and Transexual Elders Resource Center ............................. 272 

National Center on Elder Abuse ................................................................................... 274 

National Long Term Care Ombudsman Resource Center.......................................... 278 

Pension Counseling and Information Program........................................................... 280 

Pension Counseling and Information Projects.............................................................. 281 

National Pension Assistance Resource Center ............................................................ 288 

Model Approaches to Statewide Legal Assistance..................................................... 290 

National Legal Assistance Centers .............................................................................. 309 

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Senior Medicare Patrol (SMP)....................................................................................... 315 

Senior Medicare Patrol (SMP) Program – Capacity Building Grants............................ 316 

Senior Medicare Patrol (SMP) Program – Statewide Expansion Grants ...................... 368 

National Consumer Protection Technical Resource Center ......................................... 424 

Resource Centers for Older Indians, Alaska Natives, and Native Hawaiians........... 427 

Health Disparities among Minority Elderly - Technical Assistance Centers ............ 432 

National Education and Resource Center on Women and Retirement Planning ..... 437 

Eldercare Locator .......................................................................................................... 439 

National Aging Information and Referral Support Center .......................................... 441 

National Alzheimer’s Call Center.................................................................................. 443 

National Aging Civic Engagement Technical Center.................................................. 445 

Office of the Deputy Assistant Secretary for Aging ....................................................... 447 

Disaster Assistance for State Units on Aging and Tribal Organizations .................. 448 

Congressional Identified Projects.................................................................................... 452 

Organization Index ............................................................................................................ 475 

Academic Institutions ................................................................................................... 475 

American Indian, Alaskan Native and Native Hawaiian Organizations......................... 476 

Area Agencies on Aging............................................................................................... 476 

Local Government and State and Local Organizations ................................................ 477 

State Government Agencies and Units on Aging ......................................................... 479 

National Organizations ................................................................................................. 482 

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Center for Planning, Policy, and Evaluation 

The Administration on Aging (AoA) Center for Planning, Policy and Evaluation conducts the 

agency’s strategic planning, policy analysis, program development, and evaluation of 

program performance functions. The Title IV Older Americans Act (OAA) discretionary grants 

demonstrations supporting the Assistant Secretary of Aging’s priorities included in this 

section are administered by the three major units of this Center: the Office of Program 

Innovation and Demonstration, the Office of Performance and Evaluation and the Office of 

Policy Analysis and Development. 

Page 1 of 486

Aging and Disability Resource Centers 

The Aging and Disability Center (ADRC) was launched in the fall of 2003 as collaborative 

effort of the Administration on Aging (AoA) and the Centers for Medicare and Medicaid 

Services (CMS) to streamline access to long-term care supports. AoA and CMS envision 

ADRCs as highly visible and trusted places available in every community across the country 

where people of all ages, incomes and disabilities go to get information on the full range of 

long-term support options. The ADRC program provides states with an opportunity to 

effectively integrate the full range of long-term supports and services into a single, 

coordinated system State efforts to develop “one-stop shop” programs at the community level 

that help people make informed decisions about their service and support options. States are 

using ADRC funds to integrate and/or better coordinate their existing systems of information, 

assistance, and access and are doing so by forming strong State and local partnerships. 

AoA and CMS envision ADRCs as highly visible and trusted places available in every 

community across the country where people of all ages, incomes and disabilities go to get 

information on the full range of long-term support options. Three core principles of AoA and 

CMS’s vision are: 1) creation of a person-centered, community-based environment that 

promotes independence and dignity for individuals; 2) provision of easy access to information 

to assist consumers in exploring a full range of long-term support options; and 3) provision of 

resources and services that support the range of needs for family caregivers. 

During FY2010 AoA funded the second year continuations of grants awarded in FY2009 

which expand the geographical reach of ADRCs to every State and increase the number and 

coverage ADRCs with a number of States with existing ADRCs. Two competitions for new 

awards were also held In FY2010: 1) support for incorporating into existing ADRCs the 

service of option counseling where individuals could receive a full assessment of their needs 

and understand their choices for current and future supports in maintaining their quality of life 

at home or at a long term care facility; 2) support for ADRCs to adopt evidence-based care 

transition models that integrate the medical and social service systems to help older 

individuals and those with disabilities remain in their own homes and communities after a stay 

in a hospital, rehabilitation or skilled nursing facility. 

Descriptions of awards made under each of the above funding opportunities are included in 

the following Sections. 

Additional Information about AoA’s support of ADRC programs may be read on its website: 

http://www.aoa.gov/AoARoot/AoA Programs/HCLTC/ADRC/index.aspx 


Aging and Disability Resource Centers – Expansion and Enhancement 

Projects 

The Administration on Aging held a project grant award competition in FY2009 to support 

new and to enhance existing Aging and Disability Centers (ADRCs). A goal of this 

announcement was to expand the geographical coverage of ADRCs to all States. At the time 

of the announcement 45 states and territories had received grants and were supporting over 

200 ADRC sites in operation across the nation. An additional 2 states had developed ADRCs 

as part of their Community Living Program grant. An additional goal was to encourage States 

to serve Medicare beneficiaries or individuals with chronic conditions at risk of unnecessary 

re-admission to hospitals by strengthening ADRC coordination with hospital discharge 

planning programs and physician practices. 

Under this announcement, 50 awards were made in FY2009 to 48 States, Guam and Puerto 

Rico. In FY2010 continuation awards for the second of three funding years were awarded to 

49 of the 50 grants and these are included in this compendium. 

Information about the ADRC program may be viewed on the AoA website: 



Program: Aging and Disability Resource Centers 

Grant Number: 90DR0041 

Project Title: Alabama Aging and Disability Resource Center 

Project Period: 09/30/2009 – 09/29/2012 

Grantee: 

Alabama Department of Senior Services 

770 Washington Avenue, Suite 470 P.O. Box 301851 

Montgomery, AL 36130-1851 

Contact: 

Julier Miller 

Tel. (334) 242-5594 

Email: julie.miller@adss.alabama.gov 

AoA Project Officer: Kevin Foley 

Project Abstract: 

Fiscal 

Year 

Funding 

Amounts 

FY2010 $229,917 

FY2009 $246,056 

FY2008 $ 






Total $475,973 

The Alabama Department of Senior Services (ADSS) in partnership with Middle Alabama 

Area Agency on Aging (M4A) is pursing the following goal: to coordinate a personalized and 

consumer friendly approach to provide information and long-term care options, both public 

and private to meet the growing demands for long-term care services and supports for older 

individuals and those, disable or living with chronic illness for the Aging and Disability 

Resource Center (ADRC) grant to empower individuals to navigate their health and long-term 

support options. Project objectives are : 1) expand ADRC to M4A region; 2) Implement 

procedures, develop tools, and training to support hospital discharge planners and 

caregivers; 3) expand and enhance services in collaboration with the Governor’s Office of 

Disability and Independent Living Resources of Greater Birmingham to serve all target 

populations; 4) prescreen clients for potential Medicaid spend down and counsel clients on 

importance of appropriate long-term care planning; ADSS will increase IT capacity to 

implement system changes and track measures that show effectiveness of program; 5) 

ADSS and State ADRC Advisory Council will develop a 5 year plan and budget to implement 

statewide ADRCs in all AAA regions; and 6) ADSS will coordinate with Medicaid working with 

other health and human service providers to increase awareness and funding for ADRCs and 

to develop a coherent system of access to modernize the long term care system in Alabama. 




Project Title: Aging and Disability Resource Center Development and Expansion 



Alaska Department of Health and Social Services 

Senior and Disability Services 

550 W 8th Ave 

Anchorage, AK 99501 

Contact: 

Amanda Lofgren 

Tel. (907) 334-2612 

Email: amanda.lofgren@alaska.gov 

AoA Project Officer: Eric Foley 

Fiscal 

Year 

Funding 

Amounts 









Total $458,863 


Alaska is currently undergoing a large systems change to restructure the Home and 

Community Based Medicaid Waiver (HCBMW) and Personal Care Assistance (PCA) 

programs. The Aging and Disability Resource Centers (ADRCs) have an opportunity to 

become an entry point into publicly funded long term support services, as part of a statewide 

system improvement project. There are three ADRCs and the goal of this grant is to develop 

three new ADRCs in areas of the state that currently do not have an ADRC. This 

infrastructure is necessary to achieve Senior and Disabilities Services’ (SDS) goal to utilize 

the ADRCs to streamline access to services statewide. The first 18 months will be used to 

develop and foster the growth of each new site with focus on awareness and assistance. 

This is fundamental to make the ADRCs visible and trusted places for seniors, caregivers and 

individuals with disabilities to access the full range of long term care support services 

regardless of their income. The second 18 months will focus on access. This will incorporate 

and implement activities of the current ADRC Pilot Project and SDS system changes to 

realign the process of the HCBM Waivers and the PCA Program. The Hospital Discharge 

Planning Tools, developed through the Center for Medicare and Medicaid Center Real 

Choice Systems Change grant will also be implemented during the second 18 months of this 

grant into the new sites. At the end of the 36 months, Alaska will have six ADRC sites that 

meet the recommended metrics for a fully functioning ADRC. ADRCs will also develop and 

implement a five year plan and tools for program evaluation to create a sustainable ADRC 

program in Alaska. 




Project Title: Arizona Aging and Disability Resource Center 



Arizona Department of Economic Security 

Aging and Adult Services 

1789 W. Jefferson, Site Code 950A 

Phoenix, AZ 85007 

Contact: 

Cindy Saverino 

Tel. (602) 542-4446 

Email: csaverino@azdes.gov 

AoA Project Officer: Elizabeth Leef 

Fiscal 

Year 

Funding 

Amounts 









Total $458,454 


The Arizona Department of Economic Security, Division of Aging and Adult Services (ADES 

DAAS) in collaboration with the Area Agencies on Aging (AAAs), academic and community 

provider partners, will build upon the strengths of AZLinks, its Aging and Disability Resource 

Center (ADRC), to educate and develop formal linkages with federally supported Care 

Transition Programs, The project’s goal is to assist individuals with chronic conditions who 

are being discharged from hospitals to avoid unnecessary nursing home placement or 

hospital re-admissions. Project objectives are: 1) increase ADRC resources to coordinate 

with local hospital discharge planners to incorporate the Care Transitions Program; 2) modify 

the statewide data management system to enable the Arizona ADRC to gather client 

information effectively and 3) develop a five year operational plan with input from all key 

stakeholders. Expected outcomes include: more informed public and improved access to 

services; improved support for individuals and informal family caregivers; lower hospital readmission 

rates, maintenance of current level of health functioning, improved capability to 

collect and process client data, increased self-care management, and effective integration 

with existing programs using a no wrong door approach. Project products are: 1) annual data 

reports; 2) program materials for replication; 3) revised scopes of works and policies and 

procedures; 4) evaluation results; and 5) a final report. 




Project Title: Community Choices - Arkansas Care Transition Program 



Arkansas Department of Human Services 

Division of Aging and Adult Services 

PO Box 1437 Slot S530 

Little Rock, AR 72203 

Contact: 

Kris Baldwin 

Tel. 501-682-8509 

Email: kris.baldwin@arkansas.gov 

AoA Project Officer: Linda Velgouse 

Fiscal 

Year 

Funding 

Amounts 









Total $457,267 


The Choices in Living Aging and Disability Resource Center (ADRC) operating within the 

Arkansas Division of Aging and Adult Services (DAAS) is collaborating with the University of 

Arkansas for Medical Sciences (UAMS) Medical Center and the St. Joseph's Mercy Health 

Center the ADRC to adapt the model of the Colorado Care Transitions Intervention to 

implement the Community Choices project. The ADRC will develop and implement a 

replicable program working with hospital discharge planners to identify consumers to ensure 

their needs are met as they transition from an acute care setting to the community. The 

project goal is to improve care transitions by providing consumers with the support and tools 

that promote self-knowledge and self-management as they move from one long term setting 

to another. Arkansas will partner with Area Agencies on Aging, Independent Living Centers, 

providers of community health and home and community based services to achieve the 

following objectives: 1) create community partnerships that will develop and implement a 

sustainable discharge planning process; 2) streamline access to home and communitybased 

services(HCBS) that support consumers in transitioning from one long term setting to 

another; and 3) implement a variety of training opportunities to community partners to 

increase consumer choices and better coordinate services in the community. Project 

outcomes include: 1) a replicable care transition program that can be expanded statewide; 2) 

community partners who are aware of services that increase consumer choices; 3) 

individuals at high risk of nursing home admission have quicker access to HCBS; and 4) 

reduction in hospitalizations for program participants. 




Project Title: Enhancing and Expanding California's Aging and Disabiity 

Resource Center 



California State Independent Living Council 

1600 K Street, Suite 100 

Sacramento, 95814-4010 

Contact: 

Elizabeth (Liz) Paxdrai 

Tel. (916) 445-0142 

Email: liz@calsilc.org 



Fiscal 

Year 

Funding 

Amounts 









Total $436,748 

The grantee, the California State Independent Living Council (SILC), supports this three-year 

Aging and Disability Resource Center (ADRC) network enhancement in collaboration with the 

California Department of Aging, the Department of Rehabilitation, and the Health and Human 

Services Agency. The goal of the project is to enhance the California ADRC network. The 

objectives are: 1) expanding the network by one more site; 2) teaching and promoting 

practice of the Coleman Care Transitions Intervention model; 3) participation in the ADRC 

cross-agency Steering Committee work group activities; and 4) Strategic Planning to design a 

master plan to expand the ADRC Network throughout California. The expected outcomes of 

this project are: 1) increased consumer awareness of and information about long-term 

services and supports, as well as home and community-based service options; and 2) 

increased consumer understanding regarding eligibility for long-term services and supports. 

The products from this project are: A new ADRC location in California; data and lessons 

learned from promotion of the Coleman Transition Intervention; a final report, including 

evaluation results; a Website; abstracts for national conferences. 




Project Title: Expansion of Colorado's Aging and Disability Resource Center 



Colorado Department of Human Resources 


1575 Sherman St., 10th Floor 

Denver, CO 80203 

Contact: 

Todd Coffey 

Tel. (303) 866-2750 

Email: todd.coffey@state.co.us 

AoA Project Officer: Eric Weakly 

Fiscal 

Year 

Funding 

Amounts 









Total $458,750 


The Colorado Department of Human Services (CDHS) and the Colorado Department of 

Health Care Policy and Financing is conducting a three-year expansion of the Aging and 

Disability Resource Center (ADRC) known as Adult Resources for Care and Help (ARCH) in 

Colorado. The Colorado ARCH utilizes the resources and knowledge base of existing 

agencies including: the Single Entry Point (SEPs) Agencies, the Area Agencies on Aging 

(AAAs), Centers for Independent Living (CILs), and Colorado 2-1-1. The goal of Colorado 

ARCH is to improve access to information and assistance for long-term care services for 

aging and disabled adults in Colorado. Colorado ARCH coordinates with agencies to 

streamline access for both publicly and privately funded services. The objectives are: 1) 

expand and sustain a management information system (MIS); 2) enhance and expand the 

integration of evidence-based programs and education of hospital discharge planners; 3) 

expand Colorado ARCH Pilot sites to Eagle, Garfield, Grand, Jackson, Pitkin, Summit, Otero 

and Crowley Counties; 4) blend Denver and Boulder Counties into Colorado ARCH; 5) 

develop a plan to expand Colorado ARCH statewide; 6) expand Colorado ARCH to an 

additional three pilot sites; and 7) evaluate the impact of Colorado ARCH. Expected 

outcomes include: 1) long-term care services, resources, and supports are made known to 

consumers in Colorado; 2) long-term care services, resources, and supports are easily 

accessed; 3) resource Specialists improve the connections and collaboration to these 

services; and accessing the best fit for services expands the consumer's choice. 




Project Title: Connecticut's Aging and Disability Resource Center Project 



Connecticut Department of Social Services 

Aging Services Division 

25 Sigourney Street 

Hartford, CT 06106 

Contact: 

Margo Gerundo Murkette 

Tel. (860) 425-5322 

Email: Margaret.Gerundo-Murkette@ct.gov 

AoA Project Officer: Carolin Ryan 

Fiscal 

Year 

Funding 

Amounts 









Total $434,078 


The Connecticut Department of Social Services (DSS) and its State Unit on Aging (SUA), in 

partnership with the Agencies on Aging of North Central (NCAAA), South Central (AASCC) 

and Western (WCAAA) Connecticut and the Centers for Independent Living (CIL), Center for 

Disability Rights (CDR), Independence Unlimited (IU), and Independence Northwest (IN), and 

Home and Community Based Services (HCBS) provider Connecticut Community Care, Inc. 

(CCCI), and the Hospital of Central Connecticut (HCC) will partner to further expand Aging 

and Disability Resource Centers (ADRC) in Connecticut. The goal of providing consumers 

with a Single Entry Point (SEP) system to all long-term services and supports while providing 

streamlined access to all publicly funded long-term supports and services, including both 

HCBS and institutional care will be fulfilled through these objectives: 1) create new ADRC in 

the North Central Region (NCR) of Connecticut with core partners NCAAA, IU, and CCCI; 2) 

ADRC partners with HCC to pilot a new person-centered hospital discharge planning model 

,the Care Transition Intervention (CTI), in effort to reduce unnecessary hospital readmissions 

and replicate in 2 remaining regions; 3) Incorporate new ideas for sustainability including use 

of Title III-B funds; 4) formally coordinate with the State Medicaid Agency (SMA) to provide 

expedited eligibility determinations (EED); and 5) develop a Statewide ADRC operational 

plan and budget. Expected project outcomes include: 1) new ADRC; 2) new committed 

partnerships; 3) CTI model in 3 regions; 4) EED achieved; and 5) sustainable long term care 

(LTC) systems change. Expected products include: ADRC products in alternative formats; 

accommodations for consumers, and LTC Management. 




Project Title: Delaware Aging and Disability Resource Center 



Delaware Department of Health and Human Services 

Division of Services for the Aging and Adults with Disabilities 

1901 N. DuPont Highway 

New Castle, DE 19720 

Contact: 

Guy Perrotti 

Tel. (302) 255-9390 

Email: guy.perrotti@state.de.us 


Fiscal 

Year 

Funding 

Amounts 









Total $458,750 


The Delaware Division of Services for Aging and Adults with Physical Disabilities (DSAAPD) 

proposes to use funds provided through this grant to establish a new, statewide Aging and 

Disability Resource Center (ADRC). The Delaware ADRC will provide a one-stop access 

point for long-term care services and supports for older persons and adults with physical 

disabilities in the State. The ADRC will be operated by DSAAPD staff in coordination with 

partner organizations, including the Division of Medicaid and Medical Assistance, the State's 

Health Insurance Counseling and Assistance Program (SHIP), the State's Centers for 

Independent Living (CILs), and the Delaware Aging Network (DAN). Functions to be carried 

out by the ADRC will include information and awareness; options counseling; streamlined 

access to public programs; person-centered hospital discharge planning; and quality 

assurance and evaluation. Because Delaware is a single planning and service area for 

purposes of administering funds under the Older Americans Act, DSAAPD currently serves 

as a focal point for information and assistance services statewide and performs as an access 

point for many public programs. The grant will allow DSAAPD to make the infrastructure 

improvements and systems changes needed for the successful implementation of an ADRC. 

Infrastructure improvements will include the installation of a state-of-the-art call center; the 

development of a web portal for real-time referrals; the creation of an ADRC web site with a 

searchable database; and the development of management information systems needed for 

client tracking. Other improvements will include expanded training, increased coordination 

among partner agencies, and formalized support of the hospital discharge planning process. 




Project Title: Strengtheing the District of Columbia Office on Aging’s Aging and 

Disability Resource Center 



District of Columbia Office on Aging 

441 Fourth Street, NW, Suite 900 South 

Washington, DC 20001 

Contact: 

Clarence Brown 

Tel. (202) 724-4382 

Email: clarence.brown@dc.gov 



Fiscal 

Year 

Funding 

Amounts 









Total $453,889 

The goal of the District of Columbia Office on Aging and the Aging and Disability Resource 

Center (DCOA/ADRC) three year project, in collaboration with its Senior Service Network, 

collaborating partners and District hospitals, is to significantly strengthen its existing 

DCOA/ADRC program by developing and implementing a coordinated, person-centered 

hospital discharge planning component and streamlining access for family and informal 

caregivers support and services. The project's objectives are: 1) integrate the hospital 

discharge planning component into the DCOA/ADRC starting with five pre-selected hospitals 

during the first eighteen months and all District hospitals in three years; 2) develop a 

consumer cost model to accompany hospital discharge services and planning designed to 

show cost effective options that can save time and avoid frequent re-hospitalizations; 3) 

change the District's approach to and system for providing caregiving services among all 

service providers; 4) develop new informal caregiver support materials that are person 

centered, culturally competent, and targeted to low and moderate income groups for families 

post hospital discharge; and 5) increase access to information, services, sources of support 

and training for all District caregivers. The expected outcomes are: 1) the first DCOA/ADRC 

person-centered care coordination model in the District; 2) reduction in the District's rate of 

re-hospitalization and a consumer cost saving model; 3) real system change in providing 

streamlined access to caregiving services for consumers, family/informal caregivers of all 

ages; and 4) enhanced caregiving training and consumer information and support materials. 

The expected products are: consumer and family caregiver information and materials on 

hospital discharge planning; evaluation results of system changes; conference presentations; 

and reports. 




Project Title: Florida Aging and Disability Resource Center Expansion Grant 



Florida Department of Elder Affairs 

4040 Esplanade Way, Suite 315 

Tallahassee, FL 32301 

Contact: 

Abbie Messer 

Tel. (859) 414-2105 

Email: messera@elderaffairs.org 

AoA Project Officer: Caroline Ryan 


Fiscal 

Year 

Funding 

Amounts 









Total $477,048 

The Florida Department of Elder Affairs (DOEA) in collaboration with the Agency for Persons 

with Disabilities (APD) is expanding the disability population served by one of Florida’s 

existing Aging and Disability Resource Centers (ADRC) and to transition one of the current 

Aging Resource Centers (ARC) to a fully functioning Aging and Disability Resource Center. 

The goals of this proposal are to strengthen current ADRC efforts by expanding the target 

population of people with disabilities served by the ADRC in Planning and Service Area 

(PSA) 5 to include persons with developmental disabilities, transition the Aging Resource 

Center in PSA 8 to a fully functioning ADRC by expanding services to include persons with 

developmental disabilities and establish a framework for statewide implementation of ADRCs. 

The objectives include: 1) develop a training curriculum on developmental disabilities 

including supports and services; 2) educate ADRC staff, members of the service provider 

community, local coalition workgroup and other stakeholders regarding people with 

developmental disabilities; 3) enhance existing information and referral system by expanding 

resources that may be utilized for persons with developmental disabilities; 4) streamline 

access to all publicly supported long-term care options including resources for persons age 

50+ with developmental disabilities and their caregivers age 60+; 5) develop a five-year plan 

to achieve statewide coverage of ADRCs; and, 6) evaluate the project's effectiveness. 




Project Title: Georgia's Aging and Disability Resource Center Expansion Project 



Georgia Department of Human Services 

Division of Aging 

2 Peachtree Street 

Atlanta, GA 30303 

Contact: 

Cherly Harria 

Tel. (404) 656-1705 

Email: chharris@dhr.state.ga.us 


Fiscal 

Year 

Funding 

Amounts 









Total $458,773 


The goal of the Georgia Department of Human Services Division of Aging Services project is 

to expand availability of Georgia’s Aging and Disability Resource Connections (ADRCs) to all 

of the state's 159 counties and to strengthen the capacity of the ADRCs to serve all citizens 

needing long term care supports independent of age or disability type. The specific 

objectives of this proposal are: 1) add three new ADRCs in areas currently not served; 2) 

partner with the state's Quality Improvement Organization and the Center for Medicare and 

Medicaid pilot project, the Care Transitions Initiative, to establish a pilot discharge planning 

project linking the Northeast Georgia Area Agency on Aging ADRC, the Newton Medical 

Center and the two nursing homes located in Newton County; 3) add an additional ADRC 

website tool to integrate the Benefits Check up into e-forms so that applying for multiple 

benefits is easier to manage; and 4) improve the quality assurance and reporting process to 

measure performance goals and indicators. The expected outcomes include : 1) increasing 

the number of ADRCs in Georgia from six to a total of nine raising the number of counties 

served by an ADRC from 70 to 119, which represents 75% statewide coverage; 2) reducing 

readmission rates of Medicare beneficiaries discharged from hospitals in Newton county and 

avoiding unnecessary nursing home admissions; 3) increasing the number of contacts and 

individuals served by Georgia's ADRCs; and 4) developing and implementing a standardized 

customer satisfaction survey to improve ongoing quality of Georgia’s ADRC network. 




Project Title: Expansion and enhancement of Guam's Aging and Disabilty 

Resource Center Program 



Guam Department of Mental Health and Substance Abuse 

790 Governor Camacho Road 

Tamuning, GU 96913 

Contact: 

Francisco S. Reyes 

Tel. (671) 475-4646 

Email: francisco.reyes@disid.guam.gov 



Fiscal 

Year 

Funding 

Amounts 









Total $450,012 

The Guam Department of Mental Health and Substance Abuse has a Memorandum of 

Understanding (MOU) with the Department of Integrated Services for Individuals with 

disabilities to conduct a three year project to enhance its operational no wrong door Aging 

and Disability Resource Center network. Project goals include: 1) decreasing the amount of 

time between referral and intake; 2) Increasing diversions from institutional settings; 3) 

Increasing awareness about Medicare/Medicaid benefits (including Part D coverage); and 4) 

decreasing rates of hospital readmissions within 30 days of discharge. Stakeholders have 

identified three areas for needed for improvement: 1) when consumers use the program to 

locate services, they often face a complicated enrollment process; 2) when consumers use 

the program to learn about their options, there is no formal linkage to SHIP counseling; and 

3) when discharge planners can use the program to make referrals, there is no coordinated 

process for transitioning consumers to a community setting. Accordingly, Guam will use new 

ADRC funds to: 1) streamline the enrollment process by working with providers to identify a 

common dataset for intake forms, and configuring Guam's ADRC information system to 

automatically populate these forms using existing community health records; 2) Improve 

coordination with the State health Insurance Information Program (SHIP) program by colocating 

SHIP counselors at ADRC community events, and cross-training ADRC/SHIP staff; 

3) Implement person-centered discharge planning by developing a consumer preference 

survey and a community living plan template; 4) providing consumers, family caregivers, and 

discharge planners access to real time availability (waitlist) information; and 5) interfacing 

with medical records (to the extent possible) to eliminate duplication/compartmentalization of 

data; and expanding electronic community health records to include decision support tools 

that allow consumers to better manage chronic conditions while living in the community. 




Project Title: Hawaii Aging and Disability Resource Center 



Executive Office on Aging 

250 South Hotel Street, Suite 406 

Honolulu, HI 96813 

Contact: 

Noemi Pendleton 

Tel. (808) 586-0100 

Email: noemi.pendleton@doh.hawaii.gov 



Fiscal 

Year 

Funding 

Amounts 









Total $480,268 

The State of Hawaii, Executive Office on Aging (EOA) in partnership with the four Area 

Agencies on Aging (AAA), is expanding the current Aging and Disability Resource Center 

(ADRC) statewide. The overall goals are to empower Hawaii's residents to make informed 

decisions about their options and to streamline access to the services and support that elders 

and their family caregivers need. EOA strives to fully integrate the disability community and 

partners by developing a seamless, single entry point with no wrong door approach. Through 

collaboration with the disability community and key health and social service providers, 

Hawaii's ADRC will move beyond the information and assistance component to incorporate 

more in-depth options counseling, streamline access to public and private long-term 

supports, and enhance person-centered hospital discharge planning to establish a fully 

functional ADRC. The objectives are to: 1) develop a 5-year operational plan and budget for 

achieving statewide coverage of Hawaii's ADRC; 2) expand and formalize linkages with key 

aging, disability and health care providers; 3) provide options counseling training to staff on 

specific aging and disability topics (e.g., private pay services, care home placement, disability 

services); 4) make enhancements to the Hawaii ADRC website to improve access to 

information and services; and 5) maintain an integrated data collection and reporting system 

for quality assurance and evaluation. The expected outcome is that the state will have a fully 

functional ADRC for Hawaii residents to make informed decisions about their long-term 

options and to access existing services and supports. 




Project Title: Aging Disability Resource Center Grant 



Idaho Commission on Aging 

3380 Americana Terrace, Suite 120 

Boise, ID 83706 

Contact: 

Kim Toryanski 

Tel. (208) 334-3833 

Email: kim.toryanski@aging.idaho.gov 

AoA Project Officer: Keven Foley 


Fiscal 

Year 

Funding 

Amounts 









Total $458,773 

The Idaho Commission on Aging is developing policy, procedure, and infrastructure change 

at the local and state levels to take the next steps to realizing reform of Long Term Services 

and Supports (LTSS). The goal of the grant will be to empower Idahoans to navigate their 

health and long term support options, with added supports for Medicare beneficiaries or 

individuals with chronic conditions during the critical event of hospital discharge, through 

statewide Aging and Disability Resource Center (ADRC) Implementation. The objectives will 

be to: 1) amend and monitor AAA contracts to fully develop the local ADRC including nursing 

home diversion capacity; 2) develop a State Five Year Plan with all stakeholders involved; 

and 3) enhance management information systems supporting health and social service 

providers. The outcomes will include access to a well-developed long term services and 

support system throughout Idaho that provides individuals in critical pathway settings, like 

hospitals and nursing homes, with consumer-centered assistance and planning to remain as 

independent as possible in the community. Products will include required reports, evaluation 

results, and program materials for replication, and a Five Year Strategic Plan. 




Project Title: Aging and Disability Resource Center: Empowering Individuals 

to Navigate Their Health and Long Term Support Options 



Illinois Department on Aging 

Planning, Research and Development 

421 East Capitol 

Springfield, IL 62701 

Contact: 

Ross G. Grove 

Tel. (217) 524-7627 

Email: ross.grove@illinois.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $459,184 


The Illinois Department on Aging is conducting this project in partnership with the Illinois 

Department of Human Services, Healthcare and Family Services, and others. The goals of 

the project are to significantly strengthen and expand existing Coordinated Point of Entry 

(CPoE)/Aging and Disability Resource Center (ADRC) programs, facilitate an integrated 

and/or fully coordinated access to CPoE/ADRC statewide, and to establish a plan for the 

implementation of a statewide CPoE/ADRC function. Our specific objectives are to: 1) 

expand the CPoE/ADRC network from 3 to 5 sites within the first year of the grant and an 

additional two sites in the second year; 2) increase by 250% the number of individuals who 

are served by CPoE/ADRC centers (from 37,150 contacts/year to 130,000 contacts/year); 3) 

finalize and disseminate statewide standards for CPoE/ADRC to all ADRC centers in Illinois; 

4) expand utilization of the web based Enhanced Services Program (ESP) resource data 

base; 5) develop a training curriculum to include disability issues and client-directed care for 

all CPoE/ADRCs; 6) develop a comprehensive, universal intake form for all CPoE/ADRCs; 7) 

ensure that all CPoE/ADRC sites are providing high quality, person-centered long term care 

planning; 8) determine the feasibility of using ADRC tools established by other States into 

Illinois' service delivery model; and 9) establish a 5-year plan to implement CPoE/ADRC 

statewide, in partnership with DHS and HFS, and with input from key stakeholders. The 

products of the grant will be an expanded, standardized and high quality CPoE/ADRC system 

in Illinois, and a written plan to implement CPoE/ADRCs statewide. 




Project Title: Indiana Aging and Disability Resource Centers: Empowering 

Individuals to Navigate Their Health and Long Term Support 

Options 



Indiana Family and Social Services Administration 

Division of Aging Services 

402 W. Washington St., Rm. E442 

Indianapolis. IN 46204 

Contact: 

Andrea Vermeulen 

Tel. (317) 234-1749 

Email: andrea.vermeulen@fssa.in.gov 

AoA Project Officer: Ke vin Foley 

Fiscal 

Year 

Funding 

Amounts 









Total $324,062 


The State of Indiana, Family and Social Services Administration (FSSA), Division of Aging 

(DA), with support from stakeholders, is implementing a 36 month grant in the amount of 

$750,000 to enhance the operations of Indiana's Aging and Disability Resource Centers 

(ADRCs) to include a robust person-centered hospital discharge planning function. 

The goals of this project are: 1) to integrate some of Indiana’s ADRC care managers into a 

hospital discharge planning process to provide timely, on-site access to comprehensive 

Options Counseling, care management and when appropriate, Preadmission Screening; 2) to 

more effectively coordinate hospital/ADRC planning process to support a more complete 

consumer/family discharge planning process; 3) to support, at the consumer's/family's option, 

access to high quality community-based long-term care supports with increased discharge to 

community-based settings and reduced reliance on nursing home care; and 4) when a 

consumer elects to reside in the community, to ensure linkage with physicians and other 

health care supports with a goal of preventing hospital readmission or nursing home 

admission. The objectives are to: 1) develop a structure for co-location of ADRC care 

managers at a hospital; 2) develop targeting criteria for consumer/family participation in the 

project; 3) develop and test procedures, protocols and other processes of care managers 

involved into the hospital discharge planning process to support the project and further 

accomplishment of project goals; 4) develop and implement an evaluation component for the 

project; and 5) develop a five year ADRC operational plan. 




Project Title: Iowa Aging and Disability Resource Center Program 



Iowa Department on Aging 

510 East 12th Street - Suite #2 

Des Moines, IA 50319 

Contact: 

Mary Anderson 

Tel. (515) 725-3346 

Email: mary.anderson@iowa.gov 

AoA Project Officer: Elizebeth Leef 


Fiscal 

Year 

Funding 

Amounts 









Total $495,472 

The State Unit on Aging (SUA), the Iowa Department on Aging (IDA), are pursing these 

goals: 1) establish Heritage Area Agency on Aging (AAA) planning and service area (PSA) as 

an Aging and Disabilities Resource Center and 2) seek the input of key stakeholders to 

develop a five-year plan and budget for statewide ADRC coverage. The objectives of 

Goal 1 are: 1) contract with Heritage AAA to support a no wrong door approach to initially 

continue ADRC services in Linn and Johnson Counties; 2) require that, within 12 months 

after receipt of funds, ADRC services as outlined in OAA II Section 202(b)7 will be available 

in all counties of Heritage AAA PSA; 3) implement a person-centered care coordination 

component for persons transitioning from institutional settings and those at risk for rehospitalization; 

and 4) adopt a private-pay fee-for-service model in the Heritage AAA ADRC 

service area. The objectives of Goal 2 are: 1) convene a committee of key long-term 

services and supports stakeholders and 2) develop a five-year plan and budget 

recommended by the SUA, State Medicaid Agency, and State Disability Agencies that 

describes how the state will realign and coordinate the existing information and access 

functions of the state and federal programs it administers and operate ADRCs statewide. 




Project Title: Aging and Disability Resource Center 



Kansas Department on Aging 

503 S. Kansas Ave 

Topeka, KS 66603-3404 

Contact: 

Tina Langley 

Tel. (785) 368-3404 

Email: Tina.Langley@aging.ks.gov 



Fiscal 

Year 

Funding 

Amounts 









Total $584,066 

The Kansas Department on Aging (KDOA) is conducting this Aging and Disability Resource 

Center grant to ensure that the ADRC project can provide information, streamlined access, 

and assistance to all people seeking long-term care services in the state of Kansas. KDOA 

continues to create bridges between existing service delivery systems and use its ADRC 

Online Resource Manual to create seamless access to information and resources for 

consumers. With this grant it is expanding the ADRC project to include additional populations 

and systems. The project goals are to increase information and awareness of local 

resources; develop a method of providing consistent Options Counseling across agencies; 

streamline access to services by expediting eligibility determination; and improve evaluation 

of ADRC processes and procedures. The objectives are: 1) to identify local grass-roots, 

faith-based and volunteer programs to be added to the Online Resource Manual (ORM); 2) 

create an Options Counseling Toolkit; 3) provide Options Counseling training to Area Agency 

on Aging (AAA) and Center for Independent Living (CIL) staff; 4) evaluate and revise the 

existing Expedited Service Delivery (ESD) process; 5) develop a web-based ESD application; 

6) integrate the online ESD application with the current eligibility determination process; 7) 

expand the ESD process to include all HCBS waivers; 8) and develop a comprehensive 

evaluation process to use throughout the ADRC network. These activities will make the 

ADRC Online Resource Manual a more useful and user-friendly tool, increase the 

effectiveness of Options Counseling throughout the ADRC network, reduce the time 

consumers have to wait to start Home and Community Based Services, and improve our 

ability to evaluate the effectiveness of our program. 




Project Title: Kentucky Aging and Disability Resource Center Grant 



Kentucky Cabinet for Health and Family Services 

Aging and Independent Living 

275 East Main Street, 3W-F 

Frankfort, KY 40621 

Contact: 

Phyillis P. Culp 

Tel. (502) 564-6930 

Email: phyllis.culp@ky.gov 

AoA Project Officer: Keven Foley 

Fiscal 

Year 

Funding 

Amounts 









Total $458,773 


Kentucky's Department for Aging and Independent Living (DAIL) is pursuing the following 

proposed goals and corresponding objectives: Goal 1: Pilot both a new person-centered, 

hospital discharge planning model and a Universal Assessment and Plan of Care process. 

Objectives: 1) strengthen information and referral between the Green River Area Agency on 

Aging and Independent Living (GRAAIL) and local hospital; 2) provide on-site Medicaid 

eligibility; 3) implement the disease management, person centered care coordination model, 

Guided Care; 4) implement universal process in three regions; 5) evaluate impact of 

standardized processes; and, 6) disseminate project information. Goal 2: Strengthen 

existing ADRCs processes through the provision of Financial Planning and soft phone 

transfer. Objectives: 1) identify a financial expert; 2) develop a financial resource guide and, 

3) facilitate statewide training; 4) develop a relationship with the state-wide independent living 

council; and 5) replicate Massachusetts soft phone transfer. Goal 3: Develop a five year 

plan. Objective: 1) facilitate discussion with key stakeholders. The expected outcomes of 

this project are: 1) prevention of nursing home admission; 2) individuals will have improved 

access to Medicaid eligibility; 3) prevent duplication of services; and 4) ADRC callers will gain 

a better understanding of financial planning options. The products from this project are: a 

final report; ADRC processes for hospital discharge planning and seamless program entry, 

Financial Resource Guide, and a five year plan. 




Project Title: Maine’s Aging and Disability Resource Center 



Maine Department of Health and Human Services 

Office of Elder Services 

11 State House Station 

32 Blossom Lane 

Augusta, ME 04333-0011 

Contact: 

Romain Tuyn 

Tel. (201) 287-9200 

Email: Romaine.Turyn@maine.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $458,773 


Maine's Department of Health and Human Services (DHHS) will strengthen and expand 

ADRCs in Maine to help people of all ages, incomes, and disabilities, and their families, learn 

about, and access, the full range of long-term care services and supports available in their 

communities. The goal is to empower consumers to make informed decisions about longterm 

services and supports and to streamline access to existing services and supports 

through an integrated system. Objectives: 1) build effective local networks of providers and 

other stakeholders; 2) minimize confusion for consumers and families; 3) enhance individual 

choice and informed decisions by all consumers; 4) develop a standard options counseling 

protocol to inform consumer decision-making; 5) enhance services at existing ADRCs; and 6) 

expand to statewide coverage by establishing ADRCs at Maine's two other AAAs. This 

project will integrate with the Older Americans Act programs, new funding opportunities from 

the Administration on Aging, the Center for Medicare and Medicaid Services - funded Senior 

Health Insurance Information Program, and Maine's eligibility determination process. 

Currently the Area Agencies have robust relationships with the state Office of Integrated 

Access and Support (OIAS) which determines financial eligibility for Medicaid and 22 other 

programs. This grant will enable the Area Agencies to collaborate with OIAS to further 

streamline the application process by assisting and/or referring consumers to local touch 

screen kiosks in the community where consumers can electronically apply for Low-Income- 

Subsidy (LIS) and other programs. The Social Security Administration will share information 

from the LIS applications with the State, which will be accessible to ADRCs so their staff can 

provide additional assistance to consumers regarding other programs for which they may be 

eligible. 




Project Title: Aging Disability Resource Center 



Maryland Department of Aging 

301 West Preston St .,Suite 1007 

Baltimore, MD 21201 

Contact: 

Donna Smith 

Tel. (410) 767-1100 

Email: Donna.Smith@ooa.Maryland.state.gov 



Fiscal 

Year 

Funding 

Amounts 


FY2009 $271.459 







Total $522,312 

The Maryland Department of Aging (MDoA) is enhancing its current Aging and Disability 

Resource Centers (ADRCs) known as Maryland Access Point (MAP). The goal is to make 

MAP a statewide program and vehicle for facilitating and coordinating State level long term 

care reform that cuts across agencies and programs by: 1) providing coordinated and 

streamline access to public programs and existing services and supports; 2) realigning 

funding streams and 3) developing a five year operational plan and budget with stakeholders. 

Our objectives include: 1) streamlining access to MAPs by standardizing intake tools; 2) 

creating a unified application process that will be uniform; and 3) working with sites to 

integrate and restructure operations to be consistent with (MAP) workflow, staffing and 

communication and other infrastructure requirements. MAP is the vehicle through which 

other projects such as Money Follow the Person, Person Centered Hospital Discharge 

Planning Process and Nursing Home Diversion will build upon. Funding from this grant will 

involve both the current 8 MAP sites and develop two additional ones single points of entry 

into the long-term care system for older adults and people with disabilities. 




Project Title: Strategic Action Plan to Enhance Massachusetts’ Aging and 

Disability Resource Center Service Delivery System. 



Massachusetts Executive Office of Elder Affairs 

1 Ashburton Place, 5th Floor 

Boston, MA 02108 

Contact: 

Ruth Polombo 

Tel. (617) 222-7512 

Email: ruth.palombo@state.ma.us 



Fiscal 

Year 

Funding 

Amounts 









Total $475,973 

The Executive Office of Elder Affairs (Elder Affairs), in partnership with the Office of Medicaid 

(MassHealth), the Office of Disability Policies and Programs, and the Massachusetts 

Rehabilitation Commission (MRC) strengthening Aging and Disability Resource Consortia 

(ADRC) programs across all ages and disabilities and to develop a five-year operational plan 

and budget. Project objectives include: 1) develop a five-year statewide operational plan 

and budget for the ADRCs; 2) help people remain in their communities by enhancing ADRC 

and hospital and nursing home facility discharge planning relationships; 3) expand ADRC 

capacity to identify individuals at high risk of nursing home placement and Medicaid spend 

down, including the provision of a comprehensive long term care options program (Options); 

4) integrate SHINE and other cross-disability counseling/benefit planning programs more fully 

with the ADRC network; and 5) develop evaluation tools and quality improvement activities 

for the ADRCs. Project outcomes include: 1) a clear, articulate direction for ADRC activities; 

2) improved options for consumers to remain in the community; 3) greater role and 

knowledge for consumers in choosing their own services; 4) enhanced capacity for ADRC 

networks to identify individuals at greatest risk of nursing home placement and Medicaid 

spend down; and 5) better ability of state and ADRC leadership to identify and replicate 

successes within ADRC networks. 




Project Title: Michigan's Aging and Disability Resource Center Project 



Michigan Office of Services to the Aging 

P.O. Box 30676 

Lansing, MI 48909-8176 

Contact: 

Peggy J. Brey 

Tel. (517) 241-0988 

Email: breyp@michigan.gov 



Fiscal 

Year 

Funding 

Amounts 









Total $458,773 

Michigan's proposal supports Aging and Disability Resource Center (ADRC) capacity by 

using local long term care (LTC) resources to develop a statewide No Wrong Door approach. 

This model recognizes all LTC stakeholders as equal partners, and builds on lessons learned 

from Michigan's Single Point of Entry (SPE) demonstration. Goals: 1) enhance individual 

choice and support informed decision-making through person-centered planning/thinking 

(PCP/PCT) and comprehensive information and awareness; 2) provide seamless access to 

services for older adults/persons with disabilities; 3) improve collaboration between Centers 

for Independent Living (CILs), Area Agencies on Aging (AAAs) and other stakeholders. 

Objectives: 1) develop local ADRC partnerships using a No Wrong Door approach that will 

be fully functional within 5 years; 2) develop comprehensive mechanisms for unbiased, high 

quality Information and Assistance; 3) ADRC partnerships will be required to have Options 

Counseling services and they must practice the PCP/PCT approach; 4) develop/implement 

processes for streamlined access to services; 5) develop/implement a Quality 

Assurance/Evaluation plan; 6) collaborate with local hospital discharge planners to develop a 

PCP/PCT approach for responsive discharge planning; support the establishment of an 

External Advocate for all LTC services; 8) provide state-level support of local ADRC 

partnerships; and 8) embed culture change and PCP/PCT into ADRC operations. Outcomes 

anticipated are: 1) individuals have comprehensive LTC choices; 2) individuals live in their 

preferred residential setting with services/supports in place; 3) local communities have 

successful partnerships to address LTC planning/policies/services to meet individual needs; 

4) local partnerships develop relationships with hospitals to facilitate planning with individuals 

discharged to settings of choice; 5) ADRC certification is associated with positive individual 

outcomes; 6) duplication is averted by tracking individuals in a shared database; and 7) 

individuals have access to unbiased information on service providers. 




Project Title: Minnesota's Return to the Community Project 



Minnesota Board on Aging 

PO Box 64976 

540 Cedar Street 

St. Paul, MN 55164-0976 

Contact: 

Krista Boston 

Tel. (651) 431-2605 

Email: krista.boston@state.mn.us 

AoA Project Officer: Eric Weekly 

Fiscal 

Year 

Funding 

Amounts 









Total $466,268 


Our Return to the Community project is an assertive effort to change the mindset that nursing 

homes are a long-term living option for persons who could live successfully in the community. 

The project meets this purpose by developing referral protocols to support transitions and 

improve health care discharge planning. Return to the Community targets Minnesotans of 

any age who live with disabilities or chronic conditions, including those that are experiencing 

short term rehabilitative nursing home stays and those being discharged from hospitals. The 

project goal is that consumers and their families will access and receive long-term services 

and supports to successfully remain at home and avoid another institutional stay. Objectives 

are to: 1) develop referral protocols and partnerships to support nursing home transitions, 

focusing on people who have stayed beyond 90 days; 2) design and test a virtual system for 

streamlined discharge planning; 3) evaluate and report the impact of the project and 4) 

design a sustainability model. Outcomes are: 1) a person-centered options counseling 

model will be implemented statewide; 2) streamlined care transition partnerships will exist 

between hospitals and nursing homes; 3) the ADRC will become the source for triage into 

effective options counseling; 4) fewer low-need individuals will live long-term in nursing 

homes; 5) the critical loop will be closed between assessment and care planning; and public 

long-term dollars will be well-targeted to support persons with highest needs, in the most 

integrated settings possible. 




Project Title: Aging and Disabilities Resource Centers 



Montana Department of Public Health and Human Resources 

Senior and Long Term Care 

111 Sanders, P O Box 4210 

Helena, MT 59604 

Contact: 

Charles Rehbein 

Tel. (406) 444-7788 

Email: crehbein@mt.gov 

AoA Project Officer: Joseph Lugo 

Fiscal 

Year 

Funding 

Amounts 









Total $451,558 


The goal of this project is to expand the current Montana ADRC model statewide and to 

enhance the relationships between ADRCs and Independent Living Programs by working 

cooperatively to establish a no wrong door approach to service delivery. The Project's four 

major objectives to be accomplished are to: 1) establish new ADRC programs in the six 

counties in Areas IV and in Area VIII; 2) in partnership with local Independent Living 

Programs (ILPs), develop and implement a no wrong door approach to service delivery that 

melds the strengths of both networks to streamline access to long term care services; 3) 

expand the care management capabilities of all ADRCs; and 4) develop a five year plan in 

conjunction with the Montana Association of Area Agencies on Aging (M4) and ADRC work 

group partners to implement the ADRC model statewide. The expected outcomes are: 1) 

the development of a no wrong door approach to service delivery that will further streamline 

access to long term care services for consumers; 2) increased ability to meet consumer 

demands for assistance through the increased capacity of the ADRC partnerships; 3) 

enhanced care management through ADRCs; and 4) statewide coverage for the ADRC 

model. 




Project Title: Connecting Nebraska: The Nebraska Aging and Disability Resource 

Center 



Nebraska Department of Health and Human Services 

Division of Medicaid and Long-Term Care 

P.O. Box 95026 

Lincoln, NE 68509- 5026 

Contact: 

Sarah Briggs 

Tel. (402) 471-4623 

Email: sarah.briggs@nebraska.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $473,862 


Nebraska is using this Aging and Disability Resource Center (ADRC) grant to weave a rich 

array of existing resources into a fabric recognized and trusted by consumers, easily 

accessed at many points statewide. Regardless of where or how accessed, this fabric will 

connect consumers with a selection of services that is responsive to their unique needs. The 

statewide backbone of the ADRC is the existing Answers4Families web site, along with the 

many services for persons older than 60 coordinated through Area Agencies on Aging, and 

for persons with disabilities, through Independent Living Centers. Beginning with an eightcounty 

pilot area, phased implementation will establish a self-sustaining statewide network 

with two interfaces: 1) a user-friendly array of self-navigated interactive electronic 

subsystems along with telephone connections to persons trained to give information and 

assistance; and 2) a physical location to interface with a person who will help consumers 

access the combination of services they need. 




Project Title: Nevada Empowering Individuals through Aging and Disabilty 

Resource Centers 



Nevada Department of Health and Human Services 

Aging and Disability Services Division 

3416 Goni Rd., Suite 132 

Carson City, NV 89706 

Contact: 

Jeff Doucet 

Tel. (702) 486-3367 

Email: jsdoucet@adsd.nv.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $483,638 


The Nevada Aging and Disability Services Division (ADSD) and its network partners is 

building on their four years of collaborative experience to strengthen the competency and 

efficiency and to expand the availability of Aging and Disability Resource Centers (ADRCs) in 

Nevada. The goals of the Empowering Individuals through ADRC project will be to: 1) 

increase the number of ADRCs statewide; 2) improve knowledge about and the delivery of 

Options/Benefits Counseling to elders and individuals with disabilities both in institutions and 

the community; and 3) develop a five year operational plan that will sustain growth and 

quality. The objectives are to: 1) evaluate the Family Resource Center structure for 

compatibility; 2) recruit new ADRC sites in underserved areas of the state; 3) add three to six 

additional ADRC staff training modules; 4) deploy an e-learning solution; 5) improve use of 

Information and Assistance software for ADRC staff and the community at large; 6) ensure 

both collaboration with aging network and public benefit organizations and service design 

review by an advisory group; 7) develop or refine current tools for evaluation; 8) collect and 

evaluate data sets consistently; and 9) disseminate findings to support the operational plan. 

The expected outcomes are comparable performance by ADRCs in care planning and 

referral outcomes; improved access to training; adequate ADRC coverage and visibility 

statewide; and a collaborative funding plan and coordinated service choices within the 

partner network. The products are an improved website, an expanded training curriculum, an 

e-learning solution, enhanced Information and Referral software, additional ADRC sites, and 

evaluation results to support the five year operational plan. 




Project Title: New Hampshire Aging and Disability Resource Center 

Enhancement Project 



University of New Hampshire 

Institute for Health Policy and Practice 

51 College Ave., Service Bldg. 

Durham, NH 03824 

Contact: 

Susan Sosa 

Tel. (603) 962-4848 

Email: susan.sosa@unh.edu 


Fiscal 

Year 

Funding 

Amounts 









Total $474,873 


New Hampshire's ServiceLink Resource Center (SLRC) network is a fully functioning Aging 

and Disability Resource Center (ADRC). Despite this designation, the New Hampshire 

ADRC team recognizes that there are opportunities to expand and strengthen the SLRCs. 

This New Hampshire ADRC Enhancement project includes two major goals. Goal 1 is to 

strengthen the New Hampshire ADRC program, with the following objectives: 1) enhancing 

partnerships to facilitate the implementation of a No Wrong Door Model; 2) developing and 

implementing a Patient Centered Hospital Discharge Planning (PCHDP) Model; 3) expanding 

the current NH ADRC evaluation structure; and 4) enhancing information sharing capacity 

across SLRCs and partner agencies. Goal 2 of the project is to develop a five-year 

operational plan for sustaining and strengthening the fully functioning ADRC model in NH. 

Also part of Goal 2 is the regular review of the operational plan to ensure the ADRC progress 

aligns to the plan. The outcomes are to: 1) implement a No Wrong Door Model and create a 

plan for continuing the model; 2) implement a statewide PCHDP model; 3) enhance the NH 

ADRC evaluation design with new metrics and reporting, 4) improve communications 

systems across SLRCs and partner agencies; and 5) create a five year operational plan. The 

products from this project include a final report, including evaluation results; implementation 

guides for No Wrong Door Model and PCHDP for SLRCs; a cost effectiveness methodology 

for ADRC; and the 5 year operational plan. 




Project Title: New Jersey Aging and Disability Resource Connection 



New Jersey Department of Health and Senior Services 

240 West State Street 

Trenton, NJ 08625-0807 

Contact: 

Nancy E. Day 

Tel. (606) 943-3429 

Email: nancy.day@doh.state.nj.us 



Fiscal 

Year 

Funding 

Amounts 









Total $721,466 

The New Jersey Department of Health and Senior Services in collaboration with the 

Department of Human Services with the support of this three year project grant continues to 

provide the leadership, executive authority and resources to strengthen the Aging and 

Disability Resource Center (ADRC) which began in 2003. The ADRC serves as the catalyst 

for redesigning NJ's long-term support system by using a no-wrong-door approach to 

accessing home and community-based services (HCBS). With the ADRC model tested and 

partnerships in place, NJ is launching an aggressive strategy to institutionalize the business 

processes and tools statewide by December 31, 2010. Project goal one is to build 

partnership with NJ's Care Transitional Teams and the ADRCs to avoid unnecessary hospital 

readmission or nursing home placement to be accomplished by pursing these objectives - 1) 

Establish a project team to design a coordinated, multidisciplinary approach between acute 

and community settings; 2) test and evaluate the model in Camden County (the Community 

Living Program pilot site) and then expand it statewide; and 3) Use NJ's Pre-Admission 

Screening (PAS)/Pre-Admission Screening Resident Review (PASRR) hospital process to 

connect consumers to the ADRC. Goal 2 is to support NJ's leadership to rebalance longterm 

supports through cost-effective strategies with the objective of expanding the Global 

Budget Projection Process to incorporate the impact of expanded non-Medicaid HCBS 

options and ADRC interventions. Goal 3 is to ensure ADRCs are the visible and trusted nowrong-door 

to long-term supports, to be accomplished by these objectives: 1) create a webbased 

community resource center through Harmony Information Systems; and 2) expand 

ADRC statewide by December 31, 2010. 




Project Title: Aging Disability Resource Center 



New Mexico Aging and Long Term Care Services Department 

2550 Cerrillos Road 

Santa Fe, NM 87505 

Contact: 

Carlos Moya 

Tel. (505) 476-4577 

Email: Carlos.Moya@state.nm.us 



Fiscal 

Year 

Funding 

Amounts 









Total $458,773 

The goal of the New Mexico Aging and Long Term Care Services Department (NMALTCSD) 

is to significantly strengthen its existing New Mexico Aging and Disability Resource Center 

(NMADRC). This proposal involves the expansion and enhancement of the NMADRC in the 

key operational components of information and awareness, options counseling, streamlined 

access, person-centered hospital discharge planning, and quality assurance and evaluation. 

Information and awareness will continue to be provided by the existing partnership between 

the NMADRC and the New Mexico State Health Insurance Assistance Program (NMSHIP). 

Benefits Counseling is provided by telephone via the NMADRC by NMSHIP certified staff; it 

is provided at the community level via local NMSHIP Coordinators and NMSHIP volunteers. 

Options counseling and person-centered hospital discharge planning are new components of 

the NMADRC. With this funding, the NMADRC will utilize paid Options Counselors to provide 

an in depth assessment of each identified client via a newly developed NMALTSD Person- 

Centered Planning Tool. The tool is designed to help a client determine what he or she may 

need to live a healthy, safe and fulfilling life. The geographic area for this service component 

will include the counties of Bernalillo, Valencia, Sandoval, Santa Fe, Rio Arriba, Taos, and 

Dona Ana. The client base in these counties will be derived from at risk Medicare 

beneficiaries discharged from local hospitals upon referral by their discharge planners to the 

NMADRC and at risk individuals on the Home and Community Based Medicaid Waiver 

registry of the Coordination of Long Term Services (COLTS) Program. Collaboration exists 

with hospitals in the identified counties. 




Project Title: New York State Office for the Aging: Aging and Disabilities 




New York State Office for the Aging 

2 Empire State Plaza 

Albany, NY 12223-1251 

Contact: 

Gail Koser 

Tel. (518) 474-4424 

Email: gail.koser@ofa.state.ny.us 



Fiscal 

Year 

Funding 

Amounts 









Total $485,973 

The New York State Office for the Aging is supporting enhancement and expansion of its 

Aging and Disability Resource Centers with this grant. The project goal is to streamline 

access to long term care services, empower consumers to consider more informed choices 

using enhanced NY Connects options counseling, develop and implement a Consumer 

Navigator Program, and collaborate with key medical providers. Objectives are: 1) 

strengthen the promotion of NY Connects; 2) optimize choice through the availability of 

individualized options counseling; 3) increase consumer access to long term care services 

through service coordination; 4) facilitate person-centered transitions from hospitals, nursing 

homes and rehabilitation facilities; 5) establish performance goals that will ensure the 

satisfaction of consumers; and 6) advance systems change and streamline access to long 

term care services. This project builds upon the work of the Albany, Broome, and Tompkins 

Area Agencies on Aging (AAAs) and will share best practices and lessons learned with 25% 

of NY Connects programs statewide. Continuous quality improvement and evaluation will 

ensure effective and satisfactory service delivery. Measurable Outcomes are: 1) delivery of 

services to 100 people through person-centered discharge planning and 40 consumers 

through the Consumer Navigator Program; 2) develop service delivery that results in 

consumers remaining safely at home; 3) develop present and future long term care plans that 

meet self-directed criteria; 4) meet established quality performance indicators; and 5) share 

with 25% of NY Connects programs statewide. Products are a final report including 

evaluation results, tools, protocols, and training curricula. 




Project Title: State Planning for and Expansion of Aging Disability and Resource 

Centers 



North Carolina Department of Health and Human Services 

Office of Long Term Care Services 

2001 Mail Service Center; Adams Bldg; 101 Blair Drive 

Raleigh, NC 27699-2001 

Contact: 

Sabrena Lea 

Tel. (919) 715-8399 

Email: Sabrena.Lea@dhhs.nc.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $486,695 


The North Carolina (NC) Department of Health and Human Services (DHHS) is conducting a 

three-year grant for Aging and Disability Resource Centers (ADRC): Empowering Individuals 

to Navigate Their Health and Long Term Support Options. Project goals are: 1) operate 

ADRCs in 50 of 100 counties (30 counties currently covered) and plan for statewide ADRC 

coverage to serve adults with disabilities, older adults, their families, and others who support 

them; and 2) define equity and refine collaboration in the partnership between aging and 

disability programs. The approach will involve stakeholders representing disability and aging 

partners and consumers, and DHHS divisions in analyzing and planning for statewide ADRC 

implementation and building a framework for lasting partnerships. Objectives are: 1) support 

development of multi-county programs to increase ADRC coverage by 20 counties and 

identify organizations to serve as connectors facilitating statewide expansion; 2) develop a 

plan for statewide infrastructure including authority, program management and standards; 3) 

enhance collaboration between ADRCs and Community Care of NC; 4) identify and re-align 

existing, appropriate funding streams for ADRC program sustainability; and 5) create and 

implement protocols for aging and disability program collaboration. Project outcomes 

include: 1) consumers will find it easier to obtain information about and access to alternatives 

for informed service choices; 2) consumers will make fewer calls and repeat the same 

information less frequently; 3) individuals in transition will have access to options counseling; 

4) NC will have a systems infrastructure that streamlines information and access processes 

and a means to financially sustain ADRCs. Project products will be: 1) a 5-year ADRC 

expansion plan; and 2) a revised ADRC operations manual. 




Project Title: Development and implementation of an Aging and Disability 

Resource Center in North Dakota Region VII 



North Dakota Department of Human Services 

600 E Boulevard Avenue 

Bismarck, ND 58505-1250 

Contact: 

Heather Steffl 

Tel. (701) 328-4933 

Email: hsteffl@nd.gov 



Fiscal 

Year 

Funding 

Amounts 









Total $402,771 

The North Dakota Department of Human Services (DHS), which includes the State Unit on 

Aging, State Medicaid and Disability Agencies, and home and community based long-term 

care services is developing an Aging and Disability Resource Center (ADRC) in North Dakota 

Region VII. The ADRC will empower older adults and adults with physical disabilities and 

their families to make informed choices about long-term support services, and will streamline 

access to services by realigning and optimizing infrastructure and resources. North Dakota 

will develop a no wrong door network with these state and community partners: State Unit on 

Aging, Medicaid, the DHS West Central Human Service Center (aging, disability, and mental 

health service provider), county social services, Older Americans Act providers (region/tribal); 

Centers for Independent Living, State Health Insurance Counseling Program, and others. 

Objectives include: 1) naming a program director to manage the day-to-day development of 

the ADRC No Wrong Door network, 2) establishing an Advisory Council to guide ADRC 

development, 3) implementing the ADRC network in Burleigh County in Year 1, 4) expanding 

the ADRC to three more counties in Year 2; 5) developing a 5-year operational plan, and 6) 

expanding the ADRC to the rest of Region VII in Year 3. At the grant's end, region residents 

will be aware of the ADRC and will contact the network for information about long-term 

supports and assistance accessing them. Products include an online options counseling tool; 

intake, information and options counseling protocols; seamless referrals and support; no 

wrong door model; evaluation results; a final report; and sustainability plan. 




Project Title: Ohio's Front Door: Strengthening Access to the Long Term Care 

System 



Ohio Department on Aging 

50 W. Broad Street 9th Floor 

Columbus, OH 43215-3363 

Contact: 

Deanna Clifford 

Tel. (614) 644-5192 

Email: dclifford@age.state.oh.us 



Fiscal 

Year 

Funding 

Amounts 









Total $455,641 

Through this Aging and Disability Resource Center grant, the Ohio Department of Aging, in 

collaboration with Ohio's twelve Area Agencies on Aging, the Centers for Independent Living 

and other community-based partners, supports the development of a statewide front door to 

long-term care services, as envisioned by the state's Unified Long-term Care Budget 

recommendations. The goal of Ohio's ADRC project is to ensure that older adults and adults 

with physical disabilities are empowered to make informed decisions about publicly-funded 

and private pay long-term service and support options through a statewide, no wrong door 

Aging and Disability Resource Network (ADRN) enacted at the regional level. The objectives 

are: 1) to enhance information and awareness through shared resource information; 2) to 

provide person-centered, one-on-one assistance to consumers; 3) to develop consistent 

hospital discharge tools; 4) to improve access to benefits for individuals with physical 

disabilities; and 5) to put in place consumer quality assurance and evaluation tools for ADRN 

activities. The expected outcomes are: 1) collaboration among regional partners on shared 

information and resource materials as evidenced by Memoranda of Understanding; 2) 

development of materials specific to individuals with disabilities; 3) ADRN staff trained on 

person-centered thinking; 4) person-centered thinking adopted in tools, 5) materials and for 

one-on-one assistance; 6) consistent, person-centered hospital discharge partnerships and 

tools; and, 7) trained benefits analysts to assist persons with disabilities. Deliverables include 

required reports; resource materials for people with disabilities available in a variety of 

formats; person-centered tools for one-on-one assistance; and a person-centered hospital 

discharge planning toolkit. 




Project Title: Oklahoma's Aging and Disability Resource Center 



Oklahoma Department of Human Resources 

Aging Services 

2401 NW 23rd Street, Suite 40 

Oklahoma City, OK 73107 

Contact: 

Claire Dowers-Nichols 

Tel. (405) 522-4510 

Email: claire.dowers@okdhs.org 


Fiscal 

Year 

Funding 

Amounts 









Total $475,941 


Oklahoma Aging Services Division, supports this three-year Aging and Disability Resource 

Center (ADRC) project with the goal of providing all Oklahoma citizens, regardless of income, 

a no wrong door system for information and options benefit counseling regarding long-term 

care decision-making and planning. The objectives are to: 1) develop a person-centered 

information system accessible to the public, professionals and target populations offered in 

alternate formats; 2) ensure that caregivers and care receivers are supported in a way that 

honors individual choice by providing training to Information and Assistance (I&A) specialists; 

3) provide options counseling to individuals 60 and older and to people with disabilities; 4) 

streamline access to services by creating a standardized and efficient entry process for public 

and private pay services; and 5) further develop formal linkages between and among the 

public and private providers of long-term care supports by creating Memoranda of 

Understandings (MOUs) and other formal agreements. The expected outcomes are: 1) a 

shared and comprehensive resource database and providing consistent information to people 

needing assistance; 2) options counseling will enable people to make informed, cost-effective 

decisions about long-term care services and plan for their future needs; 3) systematic training 

will ensure all entry points and partners provide I&A services that include public and private 

pay benefits; 4) reduction in the rate of institutional placement; 5) reduction in average length 

of time from first contact to eligibility determination. Products will include standardized intake 

instruments, training materials, MOUs, formal protocols, documentation of cost savings, and 

a best practices document. 




Project Title: Expansion of the Aging and Disability Resource Center Program 

and Transitional Care Collaborative 



Oregon Department of Human Services and 

People with Disabilities 

676 Church Street, NE 

Salem, OR 97301 

Contact: 

Elaine Young 

Tel. (503) 373-1726 

Email: Elaine.Young@state.or.us 


Fiscal 

Year 

Funding 

Amounts 









Total $475,973 


Oregon's Division of Seniors and People with Disabilities (SPD) supports this three year 

Aging and Disabilities Resource Center (ADRC) grant in partnership with Northwest Senior 

and Disability Services (NWSDS), Oregon Cascades West Council of Governments 

(OCWCOG), and other key organizations. The goals of this project are: 1) expand ADRC 

services to 30 percent of Oregonians,; 2) complete a 5-year Strategic Plan to operate ADRCs 

statewide; and 3) support the implementation of best practices to improve transitions of 

Medicare beneficiaries across care settings and reduce unnecessary hospital readmissions. 

For Goal 1, the main objective is to strengthen the capacity of NWSDS and OCWCOG to 

meet the criteria for a fully functioning ADRC. For Goal 2, the main objective is to complete a 

gap analysis that prioritizes the work that must be completed at the local and state level to 

ensure a statewide ADRC system. For Goal 3, the main objective is to host a Transitional 

Care Collaborative that promotes strategies to address care transition issues for 

representative from hospitals, physician offices, home health agencies, AAA staff and others. 

Main outcomes include: 1) 3 AAAs that meet the criteria for a fully functioning ADRC; 2) a 

comprehensive Strategic Plan for AoA and for use in the 2011 legislative session; and 3) an 

increase in referrals from hospitals and physician offices to local Options Counseling and 

Transition Coaches. The products from this project are documented lessons learned while 

phasing in new technology, services, and staffing requirements to support a local ADRC, 

change packages for implementing Transitional Care Best Practices, abstracts for national 

conferences, and any final reports required by the Administration on Aging. 




Project Title: Rhode Island Aging and Disability Resource Center - THE POINT 



Rhode Island Department of Elderly Affairs 

Hazard Building, 74 West Rd. 

Cranston, RI 02920 

Contact: 

Corrine C. Russon 

Tel. (401) 462-0501 

Email: crusso@dea.ri.gov 



Fiscal 

Year 

Funding 

Amounts 









Total $458,773 

The grantee, the Rhode Island Department of Elderly Affairs (RIDEA), is conducting a threeyear 

extension and expansion of its Aging and Disability Resource Center (ADRC), 

established in 2005 and known locally as THE POINT. THE POINT's goal is to provide 

information about and referral to a statewide network of programs and services for seniors, 

adults with disabilities, and their caregivers. The expansion will create a partnership with the 

Department of Human Services (DHS/Medicaid), the lead State agency for the Rhode Island 

Global Medicaid Waiver, and build on formal linkages with government and community-based 

programs, as well as the state's Medicare Quality Improvement Organization (QIO), Quality 

Partners of Rhode Island. The project's objectives are to: 1) incorporate a patient coaching 

model into Options Counseling services and person-centered discharge planning; 2) with the 

QIO, develop and implement a Community Outreach Plan to increase formal linkages with 

the social services and healthcare communities; and 3) design and implement an Evaluation 

Plan that assesses service delivery (including customer satisfaction) and impact. The 

expected outcomes include: 1) achievement of the requirements to be designated as a fullyfunctional 

ADRC; 2) increased penetration into the local healthcare community; 3) improved 

customer service; and 4) a measurable association with improved local trends in healthcare 

utilization and cost, specifically related to maximizing outcomes for those who wish to receive 

community-based health care. The products from this project will include a Final Report 

reflecting a formal program evaluation and an operational design for a well-coordinated 

system of information, referral, and client/patient coaching and support to ensure optimal 

health outcomes. 




Project Title: Transitioning Area Agencies on Aging's to Aging and 

Disability Resource Centers 



South Carolina Lieutenant Governor’s Office on Aging 


1301 Gervais Street, Suite 200 

Columbia, SC 29201 

Contact: 

Denise W. Rivers 

Tel. (803) 734-9939 

Email: riversd@aging.sc.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $435,387 


The South Carolina Lieutenant Governor's Office on Aging (LGOA) is converting all Area 

Agencies on Aging to Aging and Disability Resource Centers (ADRCs) through this Aging 

and Disability Resource Centers grant proposal. This collaborative endeavor will be 

implemented in conjunction with the five Area Agencies on Aging that are not currently 

ADRCs as well as the South Carolina Department of Health and Human Services (the state 

Medicaid agency). The goal is to enable individuals with disabilities and/or in need of longterm 

care to make informed decisions regarding living environment, providers of services 

they receive, and acquisition of quality services consistent with their preferences and 

priorities through a statewide network. Objectives include: 1) expansion of the ADRC 

initiative to serve as a visible single point of entry for older adults and adults with disabilities 

in every county in South Carolina; 2) education to consumers on planning for future LTC 

needs; 3) enhancement of SC Access by adding new providers and additional topics and 

information to the statewide database; and 4) modification of the information technology 

system to streamline and simplify eligibility determination and service applications for long 

term care. 




Project Title: Development of Aging Disabilty Resource Centers in South Dakota 



South Dakota Department of Social Services 

700 Governors Drive 

Pierre, SD 57501 

Contact: 

Deb Peterson 

Tel. (605) 773-449 

Email: Deb.Petersen@state.sd.us 



Fiscal 

Year 

Funding 

Amounts 









Total $440,142 

South Dakota is at a crossroads in developing a sustainable system of long-term care 

services to meet the needs of its citizens in the near and long term. The state currently does 

not have an Aging and Disability Resource Center (ADRC), hindering access to services. 

The goals of the project are: 1) the state Aging Unit will develop an ADRC in Sioux Falls, the 

largest community in the state; and 2) working with key stakeholders, develop a plan within 

eighteen months to implement ADRCs across South Dakota within three years. The target 

population of older adults and adults with physical disabilities will benefit from achieving the 

objectives of developing a Single Point of Entry system for long term care services and 

options counseling, integrating eligibility functions for public long term care services, and 

developing a quality assurance system. These objectives will be guided by statewide and 

local advisory workgroups comprised of key stakeholders including consumers, providers, 

and state agencies. Changes to the current system include: 1) revisions to current Aging 

Unit staff duties; 2) development of person-centered intake; 3) assessment and case 

planning processes and requisite staff training; incorporation of Medicaid financial eligibility 

determinations into the ADRC; and 4) development of formal linkages between the long term 

care systems for elders and adults with physical disabilities. Outcomes include increased 

access to information about services and increased use of home and community based 

services by the target population. Products include outreach materials including a website, 

marketing plan, person-centered intake, assessment and case planning tools, staff training 

curriculum, statewide implementation plan and outcome data. 




Project Title: Aging and Disability Resource Centers: Empowering Individuals to 

Navigate Their Health and Long Term Support Options 



Tennessee Commission on Aging and Disability 

500 Deaderick Street, 8th Floor, Suite 825 

Nashville, TN 37243 

Contact: 

Cynthia Minnick 

Tel. (615) 741-3309 

Email: cynthia.minnick@tn.gov 



Fiscal 

Year 

Funding 

Amounts 

FY2010 $ 








Total $475,973 

The Tennessee Commission on Aging and Disability (TCAD) supports Aging and Disability 

Resource Centers (ADRCs): Empowering Individuals to Navigate Their Health and Long 

Term Support Options targeting older persons and adults with physical disabilities. This 

project goal is to build on the existing Tennessee ADRC project to create fully functioning 

ADRCs in all nine regions of the State and ensure ADRC concepts and functions are 

embedded in the State’s long term care system by coordinating staff, technology, 

partnerships, marketing, evaluation and accomplishing the project goals and objectives. 

Objectives are: 1) increase visibility and awareness of the existence and functions of the 

ADRC; 2) implement ADRCs that the public recognizes as a trusted, objective, reliable 

sources of information and assistance; 3) identify gaps or needs for training about 

responsiveness; 4) remove barriers that slow down ease of access to programs; 5) 

implement system changes that will streamline access and increase efficiency and 

effectiveness; 6) determine Tennessee's readiness for implementing person-centered 

hospital discharge planning; 7) monitor project goals, objectives and outcomes; 8) document 

development of nine fully functioning ADRCs; 9) enhance technology at the ADRCs and 

TCAD; 10) enhance functions of the state’s single point of entry system and ensure funding is 

embedded in the long term care system, and 11) develop 5-year operational plan and budget. 

Outcomes are: 1) marketing is coordinated and implemented; 2) healthcare professionals 

are educated; 3) ADRC staff is trained in ADRC functions; 4) barriers to access are removed, 

5) the project is embedded in the State's system; 6) reports show the project has 

accomplished its goals and objectives, and the 5-year operational plan and budget are 

completed. 




Project Title: Texas Aging and Disability Resource Centers 



Texas Department of Aging and Disability Services 

701 W. 51st Street 

Austin, TX 78751 

Contact: 

Winnie Rutlege 

Tel. (512) 438-5891 

Email: winnie.rutledge@dads.state.tx.us 



Fiscal 

Year 

Funding 

Amounts 









Total $458,773 

The Texas Department of Aging and Disability Services (DADS) is expanding and enhancing 

its current Aging and Disability Resource Center (ADRC) network by working with the ADRC 

State Advisory Council and its eight projects to standardize operations in support of fully 

functioning ADRCs. DADS is pursing two goals: 1) to enhance the capacity of the current 

project sites options counseling and support services by collaborating with hospital discharge 

planning departments to reduce hospital readmissions and by providing additional structure 

to the operation of the ADRC project sites for more uniformity of services provided; and 2) to 

expand the number of ADRC project sites to at least one project in each region. Objectives 

are: 1) adopting standards of operation using the lessons learned and the experience gained 

from the original sites three years of operation and other states' ADRCs; 2) increasing the 

capacity of ADRC projects to work with hospital discharge planning departments in at least 

one medical facility through increased funding and training opportunities because not all 

ADRC projects sites are actively involved with these departments; 3) increasing the capacity 

of Central Texas ADRC project to provide person centered care coordination through 

implementation of Guided Care model; and 4) developing a five year state plan to expand 

ADRCs statewide with extensive stakeholder input. These activities will provide DADS, the 

project sites and the Administration on Aging several products: 1) policy and procedures 

manual for ADRC operations; 2) State Plan for statewide implementation of ADRCs; and 3) 

evaluation report of progress toward attainment of goals. 




Project Title: Utah Aging and Disability Resource Center (ADRC) 



University of Utah 

Center on Aging/Geriatrics 

75 South 2000 East, RM 211 

Salt Lake City, UT 84112 

Contact: 

Maureen Henry, JD 

Tel. (785) 673-1048 

Email: Maureen.henry@utah.edu 


Fiscal 

Year 

Funding 

Amounts 









Total $458,773 


The Utah Commission on Aging through the University of Utah is creating a statewide ADRC 

in collaboration with the Utah Division of Aging and Adult Services, Division of Services for 

People with Disabilities, Medicaid Program, 211, Access Utah Network, Area Agencies on 

Aging, Centers for Independent Living, and Utah State University. Goal 1 is to establish the 

organizational structure necessary to establish the ADRC. Objectives include employing 

staff, convening committees, developing ADRC model and evaluation/reporting plan. Goal 2 

is to establish and maintain a state-wide database of long term support options. Objectives 

include assessment of the current system, developing a plan, and evaluation. Goal 3 is to 

create a statewide awareness, information, and individualized counseling system. Objectives 

include assessment of the current system, development of a plan, identification and funding 

of pilot site, and evaluation. Goal 4 is to create a seamless single point of entry to publicly 

funded long term support programs. Objectives include assessment of the current system 

and development of plan. Goal 5 is to create a care transition system that provides 

individuals and caregivers with timely and accurate information about long term support 

options. Objectives include an assessment, consideration of models, and development of a 

plan. The target population is individuals aged 60 and older and disabled adults aged 18 and 

older, statewide. Identified products will be an operational ADRC, a statewide computerized 

database of information, a five year state plan, and an online application for Medicaid long 

term support programs. 




Project Title: Vermont Aging and Disability Resource Center 



Vermont Department of Disabilities, Aging and Independent Living 

Disability and Aging Services 

103 South Main Street, Weeks Building 2nd Floor 

Waterbury, VT 05671-1601 

Contact: 

Merle Ewards-Orr 

Tel. (802) 241-4496 

Email: merle.edwards-orr@ahs.state.vt.us 


Fiscal 

Year 

Funding 

Amounts 









Total $458,123 


The Vermont Department of Disabilities, Aging and Independent Living (DAIL) is 

strengthening the Vermont Aging and Disability Resource Connection (ADRC) statewide and 

develop a five year operational plan and budget in collaboration with its ten core partner 

agencies. Project objectives include: 1) develop a five year operational plan and budget; 2) 

develop warm transfer capability among partner agencies to facilitate timely and efficient 

referrals; 3) build a marketing strategy to bring the ADRC statewide to the public and key 

stakeholders; 4) establish AIRS I/R/A professional staff capacity at each ADRC core partner 

agency; 5) improve person centered hospital discharge planning in collaboration with the 

Community Living Program (CLP) project efforts; 6) pilot a new model(s) of discharge 

planning in at least two regions of the state; 7) identify and develop effective partnership 

strategies with the State Medicaid Office on eligibility determination processes; and (8 

develop a quality improvement plan including vehicles for ongoing consumer involvement. 

Project outcomes include: 1) a statewide fully functional ADRC; 2) a sustainable five year 

operational plan and budget; 3) professionally staffed information, referral and assistance 

service capacity in the ten partner agencies; 4) enhanced options counseling and decision 

support functions with the Vermont ADRC that incorporates the Community Living Program 

(CLP) goals and consumer preference to remain at home for as long as possible; 5) a 

collaborative, person centered discharge planning process in partnership with the CLP, local 

hospitals and nursing homes; and 6) a quality improvement plan supporting a five year ADRC 

operational plan. Project deliverables include a five year plan and budget, project reports, 

training materials, and conference presentation materials, such as abstracts. 




Project Title: Aging and Disability Resource Centers: Empowering Individuals 

to Navigate Their Health and Long-Term Support Options 



Virginia Department on Aging 

1610 Forest Avenue, Suite 100 

Richmond, VA 23229 

Contact: 

Katie Roeper 

Tel. (804) 662-7047 

Email: katie.roeper@vda.virginia.gov 



Fiscal 

Year 

Funding 

Amounts 









Total $475,969 

Virginia's No Wrong Door (NWD) initiative strives to streamline access to information and to 

public/private long-term services and supports for seniors and adults with disabilities - 

maximizing opportunities to live at home and engage in community life. The Virginia 

Department for the Aging is developing new NWD/Aging and Disability Resource Center 

(ADRC) communities and significantly enhance existing ADRC operations in partnership with 

the Department of Medical Assistance Services, Department of Rehabilitative Services, 

Virginia Hospital/Healthcare Association, Area Agencies on Aging, Centers for Independent 

Living (CIL), and hospitals. Project goals are to: 1) expand geographically growing closer to 

statewide coverage of Virginia's NWD/ADRC model of service delivery; 2) expand functionally 

enhancing NWD/ADRC technology for optimal use by disability service providers; and 3) 

expand collaboratively developing best practices in coordination of transition planning for 

NWD/ADRCs and hospital discharge planners. Objectives are: 1) establishing four new 

NWD/ADRC communities; 2) enhancing technology to improve service coordination for 

people with disabilities; 3) conducting feasibility studies to interface with hospital discharge 

planning information systems and the State Health Insurance Information Program reporting 

system; 4) developing protocols for coordinating transition/service plans in five existing 

NWD/ADRC communities; 5) cultivating a statewide approach to foster education about and 

support for person-centered care coordination; and 6) developing a marketing plan for 

NWD/ADRC communities. Expected outcomes are: 1) four new ADRCs serving 23 

additional localities; 2) an increase in individuals served through ADRCs; 3) addition of five 

CILs and ten case managers; 4) five ADRCs collaborating with discharge planners at 15 

hospitals, resulting in a reduction in readmissions; increased consumer/caregiver 

understanding of options when leaving a hospital; and 5) increased consumer satisfaction 

and provider efficiency. 




Project Title: Aging and Disability Resource Center Expansion in 

Washington State 



Washington Department of Social and Health Services 

Aging and Disabilities Services Administration 

640 Woodland Square Loop SE 

Lacey, WA 98503 

Contact: 

Susan L. Shepherd 

Tel. (360) 725-2418 

Email: shephsl@dshs.wa.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $459,668 


Washington State Department of Social and Health Services-Aging and Disability Services 

Administration (DSHS-ADSA), supports this three year Aging and Disability Resource Center 

(ADRC) expansion project in collaboration with four Area Agencies on Aging (AAAs), 

interested stakeholders, and constituents. The goal of the project is to achieve significant 

progress toward statewide expansion of Washington State's ADRC program. The approach 

is to initiate and evaluate the expansion of ADRCs and demonstrate potential efficiencies and 

effectiveness ADRCs provide by employing person-centered principles in navigating longterm 

support options. The objectives are to: 1) achieve significant progress in establishing 

three new ADRC pilot sites; 2) convene a statewide ADRC planning and policy committee; 3) 

develop a five year operational plan and budget for achieving statewide coverage of fully 

functional ADRCs; 4) facilitate training and technical assistance for ADRC pilot site staff and 

partners; 5) enhance interagency relationships and partnerships with disability, long-term 

support option experts, and advocacy organizations; 6) evaluate the impact of the ADRC 

program; and 7) disseminate project information. The expected outcomes of this ADRC 

expansion project are: 1) four well functioning ADRC sites in Washington State; 2) an ADSAapproved 

operational plan and budget for statewide coverage of ADRCs; 3) methodology for 

determining cost savings related to ADRC catchment areas; 4) project evaluation reflecting 

project results; and 5) consumers more capable of making decisions about long term support 

options. The products from this project are: a final report, including evaluation results and 

lessons learned; a five-year operational plan and budget for statewide expansion; ADRC 

program standards; and established relationships and protocols with disability, long-term 

support option experts, and advocacy organizations. 




Project Title: VITALS - Vital Aspects of Life Services 



West Virginia Bureau of Senior Services 

1900 Kanawha Boulevard East 

Charleston, WV 25305 

Contact: 

Barbara Reynolds 

Tel. (304) 558-3317) 

Email: breynolds@wvseniorservices.gov 



Fiscal 

Year 

Funding 

Amounts 









Total $458,763 

The West Virginia Bureau of Senior Services is partnering with hospitals and Aging and 

Disability Resource Centers (ADRCs) to develop a person-centered discharge planning 

process in a program named VITALS Vital Aspects of Life Services. The goal is to reduce the 

number of hospital readmissions for adults with a diagnosis of diabetes mellitus, chronic 

obstructive pulmonary disease, congestive heart failure, status post coronary bypass surgery, 

or hip fracture. There are five objectives: 1) develop a discharge planning kit that contains 

an assessment/service plan and information regarding long-term care options and multiple 

provider agencies to facilitate individual choice; 2) enhance existing partnerships between 

ADRCs and hospital discharge planners in order to arrange and ensure a person-centered 

discharge process; 3) Develop a guided care model for follow-up after discharge that 

focuses on chronic disease and medication self-management, nutrition, and access to proper 

follow-up care; 4) evaluate the effectiveness of the project in deterring future hospital 

admissions; and 5) further strengthen the ADRCs and the long-term care system in West 

Virginia by recommending systems change based on evidence and lessons learned. There 

are four expected outcomes: 1) the pilot hospitals will see a decrease in readmissions; 2) 

patients involved will have greater input and choice in their discharge planning process; 3) 

both Medicare and Medicaid will experience a cost savings; and 4) ADRCs will be 

strengthened by VITALS to make them more fully functional and to optimize use of existing 

funding. Policymakers will subsequently be educated and systems change recommended. 




Project Title: Improving Quality and Customer Satisfaction with Information 

and Assistance, Options Counseling 



Wisconsin Department of Health Services 

Long Term Care 

! West Wilson 

Madison, Wisconsin 53707 

Contact: 

Kristen Felten 

Tel. (608) 267-9719 

Email: Kristen.Felten@Wisconsin.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $478,636 


The Wisconsin Department of Health Services has a plan in place to expand Aging and 

Disability Resource Centers (ADRC) statewide by 2012. This plan is supported by the 

Governor and the funding approved in the current state biennial budget. If awarded this grant 

opportunity. The state's goals are to significantly strengthen Wisconsin's ADRCs by building 

upon new and previous learning regarding the quality of, and customer satisfaction with, 

access to publicly funded long term care programs through the ADRC, and information and 

assistance and options counseling services, as well as achieving a reduction in unnecessary 

hospital readmissions. To achieve these goals, the objectives are: 1) to perform a quality 

evaluation and customer satisfaction survey regarding information and assistance and 

options counseling services with 16 new ADRCs not included in the 2008 study, and repeat 

the evaluation with the original 18 participating ADRCs to demonstrate improvement based 

upon the learning and identify areas needing additional support; 2) develop quality indicators 

of customer satisfaction with access to publicly funded long term care programs and to 

perform an evaluation of this service with all fully-functioning ADRCs; 3) to make funding 

available to individual ADRCs to strengthen and enhance their services based upon the 

results of each of the quality evaluations; 4) implement a specific plan with the Milwaukee 

County Aging Resource Center (the largest Wisconsin ADRC) to further streamline access 

and improve customer satisfaction; and 5) refine and strengthen existing connections 

between ADRCs, hospital discharge planning and home health agencies. 




Project Title: The Wyoming Aging and Disability Resource Center Project 



Wyoming Department of Health 

Aging Division 

6101 Yellowstone Rd., Suite 259B 

Cheyenne, WY 82002 

Contact: 

Debbie Walter 

Tel. (307) 777-5048 

Email: debbie.walter@health.wyo.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $300,000 


The Wyoming Department of Health/Aging Division supports this three year project in 

collaboration with our local independent living organizations and other related state 

programs. The objectives are: 1) serve as a visible and trusted source of information to our 

aging and/or developmentally disabled citizens including both institutional and home or 

community based care; 2) provide personalized and consumer friendly assistance to 

empower consumers to make informed decisions about their care options; 3) provide a 

streamlined and coordinated access to all care options so consumers can get the care they 

need through an single entry point (SEP) intake process; 4) assist individuals plan ahead for 

their future long-term care needs; and 5) assist Medicare beneficiaries to understand and 

access the Prescription Drug Coverage and prevention benefits under the Medicare 

Modernization Act. The approach is to develop at least one and potentially two-three Aging 

and Disability Resource Center site(s) to provide statewide coverage through a toll-free 

number system within the first 12 months of the project. The expected outcomes are: 1) 

simplified access to services and supports, eligibility determinations, and information for 

consumers who may find it difficult to navigate through the system on their own; 2) 

streamlined process of referral to other local, state and federal resources; and 3) access for 

every citizen to the services and supports they need. The products will be: on-going reports 

to the Administration on Aging (AoA) regarding the number and type of consumers served; 

survey evaluation results indicating consumer satisfaction with the process; website detailing 

program services and providers; and abstracts for national conferences. 


Aging and Disability Centers - Options Counseling 

The Administration on Aging (AoA) held a grant competition in FY2010 to support projects to 

strengthen, develop and/or implement a comprehensive set of standards they can use to 

guide, monitor and continually improve the delivery of Options Counseling and Assistance 

within the context of their Aging and Disability Resource Center (ADRC) systems. 

The projects awarded in FY2010 based on this competition will help States to standardize 

options counseling delivery policies and procedures, identify and invest in staff training and 

preparation, and implement common client tracking procedures for assessing the performance 

of Options Counseling across their ADRCs. 


Program: Aging and Disability Centers – Options Counseling 

Grant Number: 90OC0006 

Project Title: Arizona Links Standards for Options Counseling 

Project Period: 09/30/2010 – 09/29/2012 






Contact: 

Melanie Starns 

Tel. (602) 542-2591 

Email: mstarns@azdes.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $499,970 


The Arizona Department of Economic Security (DES), Division of Aging and Adult Services 

(DAAS) will strengthen statewide access to comprehensive Options Counseling (OC) through 

the Arizona Aging and Disability Resource Center (ADRC). Collaboration with existing ADRC 

partners and coordination with access-related resources will achieve the goal of developing 

of standards for OC in Arizona and fully implement OC using these standards in one existing 

ADRC site. The approach is to infuse OC into ADRC partner organizations providing 

Information and Referral (I&R) and Case Management services, clearly defining OC through 

standards for training and service delivery. Objectives are: 1) develop statewide standards 

that address the goal and objectives of OC in Arizona; 2) establish the infrastructure and 

protocols needed to implement the OC standards in Maricopa County; 3) provide OC in 

Maricopa County at the Area Agency on Aging (AAA), Region One, Inc., and the Arizona 

Bridge to Independent Living (ABIL), using the standards and protocols; 4) monitor and 

evaluate the OC service delivery, outcomes, and protocols; and 5) participate in development 

of national standards for OC. Expected outcomes include: 1) increased public awareness of 

OC; 2) better preparing families for aging and caregiving responsibilities; 3) mitigating the 

need for crisis management; 4) increased utilization of community-based options, including 

private pay, reducing reliance on public funding and avoiding premature institutionalization; 

and 5) an increase in consumer-directed planning and utilization of consumer-directed 

options. Products include a comprehensive set of standards for OC in Arizona, an evaluation 

plan, semi-annual reports, and a final report. 




Project Title: California Options Counseling Quality Improvement 



California Health and Human Services Agency 

1600 9th Street room 460 

Sacramento, CA 95814-6439 

Contact: 

Karol Swartzlander 

Tel. (916) 651-6693 

Email: KSwartz2@chhs.ca.gov 



Fiscal 

Year 

Funding 

Amounts 









Total $510,082 

California’s Options Counseling Quality Improvement Project will inform state and federal 

policy by developing, implementing and evaluating a comprehensive set of Options 

Counseling Standards with three Aging and Disability Resource Connections (ADRCs) and 

one Money Follows the Person (MFP) Demonstration Lead Organization. Two goals will 

guide this critically needed project: Goal 1 - Options Counseling, a core ADRC service in 

California, will be conducted with an enhanced service framework including scope of practice 

and staffing standards. Key objectives for this goal are: 1) to identify and develop an 

enhanced Options Counseling framework – core service elements, methods, scope of 

practice and staffing standards, etc.; 2) to develop a training curriculum and provide training; 

3) to pilot the new framework; and 4) to create an Options Counselor Corner on the state’s 

long-term care website, www.CalCareNet.ca.gov. Goal 2 - the state will have uniform criteria 

and a standard process for designating ADRCs and monitoring core ADRC functions: 

Information and Assistance (I&A); Options Counseling; Short Term Service Coordination; 

and, Care Transition Services. Key objectives for this goal are: 1) to collaborate with key 

stakeholders in the planning and expansion of ADRCs; and 2) to establish an application 

process for ADRC designation. Expected outcomes for this project include: 1) improved 

Options Counseling services for consumers; 2) an enhanced ADRC core service structure 

with defined standards; and 3) a viable ADRC application and statewide expansion plan. 

Products from this project include the following deliverables: California Options Counseling 

Handbook, Options Counseling Training Curriculum, Options Counselor Corner (web page), 

State Uniform ADRC Designation Criteria and Application Process, Evaluation Plan, and a 

Final Report. 




Project Title: Development and Implementation of Standardized Procedures 

for Options Counseling within the Aging and Disability Resource 

Center (ADRC) Program 



Colorado Department of Human Resources 



Denver, CO 80203-1714 

Contact: 


Tel. (303) 866-2750 



Fiscal 

Year 

Funding 

Amounts 

FY2010 $492.469 








Total $492.469 



Health Care Policy and Financing (HCPF) is conducting a two-year project development and 

implementation of standard operating procedures for options counseling within the Aging and 

Disability Resource Center (ADRC) known as Adult Resources for Care and Help (ARCH) in 

Colorado. The Colorado ARCH utilizes the resources and knowledge base of existing 

agencies including; the Single Entry Point (SEPs) Agencies, the Area Agencies on Aging 

(AAAs), the Centers for Independent Living (CILs), and the Colorado 2-1-1 (2-1-1). The goal 

is to develop and implement a standardized procedure for options counseling to ensure all 

consumers statewide receive accurate and effective information to assist them in making 

decisions in their long-term care needs. The Colorado ARCH has contracted with an 

evaluation consultant to evaluate and determine the most effective operating procedures. 

The objectives are to: 1) evaluate Current Operating Procedures for Colorado ARCH Options 

Counseling; 2) develop Standard Operating Procedures for Colorado ARCH Options 

Counseling; 3) determine Outcomes and Tracking Methods; 4) design an In-take and 

Assessment Tool; 5) identify and Invest in Training for Resource Specialists; 6) implement 

Standard Operation Procedures in all six ARCH sites; 7) participate in the National 

Collaborative Process; and 8) evaluate the New Standard Operating Procedures for Colorado 

ARCH Options Counseling. 




Project Title: Connecticut's ADRC Options Counseling and Assistance Program 






Hartford, CT 06106-5033 

Contact: 

Jennifer Throwe 

Tel. (860) 424-5862 

Email: Jennifer.Throwe@ct.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $500,000 


Connecticut (CT) Department of Social Services, State Unit on Aging, Agency on Aging of 

South Central CT, Western CT Area Agency on Aging, Center for Disability Rights and 

Independence Northwest will continue partnering to expand CT Aging and Disability 

Resource Centers (ADRCs). The grant will strengthen CT’s existing South Central and 

Western ADRC Options Counseling (OC) program through more coordinated Operating 

Protocols for guiding, monitoring and improving delivery of OC. CT will implement client 

tracking procedures for assessing performance, quality assurance (QA) and evaluation of OC 

with University of Connecticut Center on Aging, Statewide ADRC Committee, ADRC 

Operating Protocol Workgroup, ADRC consumers and staff, and two Community Choices 

Councils. CT ADRC staff will participate in federal workgroups/conference calls and attend 

project national meetings to develop a minimum set of standards for OC. The goal is to 

provide consumers high-quality self-determined OC experiences through two ADRCs capable 

of including assessment, information, assistance and streamlined access to public and 

privately funded long-term services and supports. Objectives: 1) update existing OC 

materials; 2) develop OC training and certification program; 3) develop OC QA and 

Evaluation tools and metrics; 4) strengthen OC marketing; 5) pilot ADRC internal workflow 

changes; 6) engage OC partnership activities at all levels; 7) strengthen CT’s ADRC 

Operating Protocols; and 8) improve ADRC management information system (MIS) 

capabilities for OC. Expected outcomes include improved staff training, QA and Evaluation; 

and updated OC materials; and management information technology tracking capabilities. 

Products include: revised OC marketing materials; updated OC guides and training manual; 

OC Certificate Program for improved staff training; revised ADRC Operating Protocols; QA 

and Evaluation tools to manage OC; MIS OC enhancements; consumer accommodations. 




Project Title: Strengthening the District of Columbia Office on Aging/Aging and 

Disability Resource Center through Options Counseling Program 




441 Fourth Street, NW, Suite 900S 


Contact: 

Dr. Clarence Brown 

Tel. (202) 724-5622 




Fiscal 

Year 

Funding 

Amounts 









Total $500,000 

The District of Columbia Office on Aging and the Aging and Disability Resource Center’s 

(DCOA/ADRC) goal is to significantly strengthen its ADRC’s Options Counseling and 

Assistance function within its one-stop, long term care services and support system for 

individuals and families of all ages, income or disability. During a two year program period, 

DCOA/ADRC will achieve the goal by accomplishing the following objectives: 1) 

collaboratively develop and implement a state-wide comprehensive set of standards to guide, 

monitor and continually improve the delivery of Options Counseling and Assistance for the 

District’s DCOA/ADRC system, its partners and consumers; 2) train fifty (50) program 

planners, managers, front line staff within DCOA/ADRC network on the standards developed 

and on the Technical Assistance Exchange (TAE) Options Counseling Curriculum; 3) 

enhance DCOA/ADRC information technology (IT) client tracking system and protocol 

(CSTARS) to meet new Options Counseling standards and for assessing performance; 4) 

participate in a collaborative process with other grantees, federal agency staff, technical 

assistance (TA) providers and stakeholders to develop a set of minimum national standards 

for Options Counseling and Assistance; and 5) monitor, track and evaluate the delivery of 

options counseling relative to business operations and consumer outcomes. The expected 

outcomes and products are: 1) a strengthened statewide DCOA/ADRC Options Counseling 

function; 2) implementation of state-wide standardized options counseling delivery policies 

and procedures; 3) fifty (50) trained professionals to counsel and advise consumers and their 

families across ages and disabilities; 4) evaluation findings and report; 5) program 

sustainability at end of grant period; 6) enhanced options counseling IT; and 7) final report as 

required by the Administration on Aging and Center for Medicare and Medicaid Services. 




Project Title: Implementing the Affordable Care Act: Options Counseling and 

Assistance Programs 





Tallahassee, FL 32301-7000 

Contact: 

Abbie Messer 

Tel. (850) 414-2105 

Email: messera@elderaffairs.org 



Fiscal 

Year 

Funding 

Amounts 









Total $515,013 

The Florida Department of Elder Affairs, in collaboration with the Area Agency on Aging of 

Pasco-Pinellas, Inc., (AAAPP) is developing state-specific standards, expand long-term care 

(LTC) options counseling for the Aging and Disability Resource Center (ADRC) in Planning 

and Service Area (PSA) 5 and participate in the collaborative process to establish minimum 

national standards. The goal is to implement standard operating procedures for options 

counseling in the ADRC by training and preparing staff to offer options counseling to adults of 

all ages and disabilities in PSA 5. The objectives include the following: 1) develop and 

implement a comprehensive set of standards that define policies and procedures for options 

counseling; 2) train options counselors to follow the new standards; 3) expand options 

counseling to include adults of all ages and all disabilities; 4) gather feedback and evaluate 

the effectiveness of the new standards to improve future outcomes; and, 5) collaborate with 

state, local and national partners in the development of national standards. The expected 

outcomes of this proposal are to create state standards that increase the knowledge of 

consumers and caregivers in their understanding of available long-term care options without 

regard to age or disability and to participate in the collaborative process in the creation of 

national standards to guide the delivery of options counseling. 




Project Title: Illinois Aging and Disabilities Resource Center Options 

Counseling Project 




Planning, Research and Development. 

421 East Capitol, #100 

Springfield, IL 62701-1789 

Contact: 

Ross Granville 

Tel. (217) 524-7627 



Fiscal 

Year 

Funding 

Amounts 









Total $457,160 


The Illinois Aging and Disability Resource Center (ADRC) project is developing, implementing 

and evaluating Options Counseling comprehensive standards with two ADRCs located in 

urban and rural regions of the state. AgeOptions, the Area Agency on Aging and ADRC for 

the suburban Chicago area, will work with its ADRC collaborating agencies to develop and 

implement Options Counseling standards and procedures that meet national criteria and are 

determined to be effective for their diverse urban service area. AgeOptions, based upon their 

ADRC experience, will submit a plan (Plan) to Illinois Department on Aging (IDoA) 

recommending standards and implementation approaches for the delivery of Options 

Counseling statewide. The Plan will include input from Northwestern Illinois Area Agency on 

Aging (NIAAA) which is developing and implementing Options Counseling standards at its 

ADRC site in Rockford, and its future ADRC site in rural Whiteside County. IDoA will ensure 

the Plan considers the needs of both urban and rural ADRCs and their clients statewide. The 

Plan will assist IDoA to standardize Options Counseling delivery policies and protocols, 

identify and invest in staff training and preparation, and implement common client tracking 

procedures for assessing the performance of Options Counseling in all ADRCs in Illinois. 

IDoA and the ADRCs look forward to participating in a collaborative process with the AoA and 

all relevant stakeholders to define a set of minimum national standards for the delivery of 

Options Counseling, addressing core competencies, minimum qualifications and protocols for 

client tracking and performance measurement. Designated staff will attend national 

meetings, participate in meaningful discussions and submit reports as required. 




Project Title: Options Counseling in Iowa 




Elder Programs and Advocacy 

510 East 12th Street, Suite 2 


Contact: 

Debi Meyers 

Tel. (515) 725-3325 

Email: debi.meyers@iowa.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $499,653 


The Iowa Department on Aging (IDA) is committed to develop, standardize and expand Aging 

and Disability Resource Centers (ADRCs) for eventual implementation in Iowa Area Agencies 

on Aging (AAA) and disability community partner agencies for citizens who need person 

centered assistance, Options Counseling, and support in long term planning. The current 

ADRCs in two Area Agencies on Aging are developing and refining state specific standards 

for the ADRC Options Counseling and Assistance function. We are reviewing national 

policies and procedures in collaboration with IDA, community and advisory partners. These 

standards will define the Options Counseling process. This will include developing standards 

for employment of options counselors, staffing ratios, client tracking, and the evaluation 

process for consumer satisfaction. Additional standards will include outcomes development, 

referral effectiveness, and uniform Information technology (IT) and data collection. To ensure 

uniform standards application, option counselors and coordinators will attend two mandatory 

state trainings: one on developed standards, followed by one for standard’s evaluation and 

problem solving. In addition, this grant enables the Heritage Area Agency on Aging ADRC to 

provide targeted outreach to minority and non-English speaking populations with an Options 

Counselor serving seven counties by establishing satellite sites within targeted 

neighborhoods and rural communities. The Hawkeye Valley Area Agency on Aging ADRC 

will expand Options Counseling to eight additional counties. The Iowa ADRCs, IDA, and 

advisory committees will develop a sustainability plan for the ADRCs for their continuation. 

The IDA and ADRCs will comply with grantor reporting requirements. Four project 

representatives will attend one national meeting annually and IDA and ADRC personnel will 

actively participate in the collaborative development of minimum national standards. 




Project Title: Aging and Disability Resource Center (ADRC) Options Counseling 

and Assistance Programs in Maine 





State House Station 11 

Augusta, ME 04333 

Contact: 

Cheryl Ring 

Tel. (207) 287-5160 

Email: cheryl.ring@maine.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $500,000 


Since 1993, Maine has systematically reduced reliance on institutional long-term care in favor 

of quality, affordable home-and-community-based options for consumers and families. 

Reliance on nursing home care has declined dramatically since that time, home care has 

increased, and administrative costs and per person expenditures have decreased, enabling 

us to serve more people with only modest increases in total spending. The goal of this 

project is to continue to capitalize on these strengths by developing a consistent, clear, and 

coordinated approach to options counseling in order to provide consumers with information, 

counseling, and support needed for them to make informed decisions about available options 

that meet their needs. The desired outcome of this effort will be improved quality of life for 

those who have received options counseling. Our objectives include: 1) develop standard 

policies and procedures for the provision of options counseling by Maine’s five ADRCs; 2) 

clarify and define roles and responsibilities; 3) implement the standards statewide; 4) develop 

a coordinated assessment of individuals’ needs; 5) provide training; 6) establish a continuous 

process improvement feedback loop; and 7) actively participate in the national discussion on 

options counseling standardization. Maine’s target population is adults of any income-level, 

setting or circumstance, anywhere in the state, having any type of disability, who contact or 

are referred to, one of our five ADRCs. Empowering consumers to make highly-informed 

decisions about their long-term support needs is an expected outcome. 





Assistance Program 



Maryland Department on Aging 

Long Term Care Services 

301 West Preston Street, Suite 1007 

Baltimore, MD 21201-2374 

Contact: 

Stephanie Hull 

Tel. (410) 767-1107 

Email: sah@ooa.state.md.us 


Fiscal 

Year 

Funding 

Amounts 









Total $500,000 


The Maryland Department of Aging is developing standards and requirements for Options 

Counseling (OC) for the Maryland Access Point (MAP), Maryland’s Aging and Disability 

Resource Center (ADRC). MAP is an integral component of Maryland's rebalancing initiative 

which includes the Money Follows the Person (MFP) Demonstration, the Community Living 

Program (CLP) and the Person Centered Hospital Discharge Program (PCHDP). We are 

creating an OC workgroup under the state MAP Advisory Board that includes representatives 

from the MAP sites and key stakeholders. This workgroup is developing protocols for OC 

during the initial intake, assessment and care planning, and case management. These 

protocols guide MAP staff as they assist individuals to make informed choices about longterm 

supports and other benefits. These protocols address the participant-directed option 

that are implemented as part of the CLP and the Veterans Self Directed Integrated Care 

Program; and these protocols will be applied to the MFP, PCHDP and SHIP Medicare 

counseling programs. Infrastructure to support OC will include: 1) automated tools to support 

the implementation of these standards; 2) a data-driven continuous quality improvement 

(CQI) process; and 3) in-person and web-based training tools. We are piloting these 

standards and protocols in Howard County, which has been a leader in our MAP program. 

The Maryland Disability Law Center (the State Protection and Advocacy Agency, and the 

Freedom Center, the Howard County regional Center for Independent Living have formal 

roles in training and reviewing standards. The OC protocols will be made available to all 

partners participating in the MAP “no wrong door” initiative. Finally, we are developing plans 

for implementing these protocols statewide. 




Project Title: Massachusetts Options Counseling Standards Initiative 




Program Planning and Management 

1 Ashburton Place, Fifth Floor 

Boston, MA 02108-1516 

Contact: 

Dr. Ruth Palombo 

Tel. (617) 222-7512 



Fiscal 

Year 

Funding 

Amounts 









Total $500,000 


The Massachusetts Executive Office of Elder Affairs (Elder Affairs), in partnership with 

Massachusetts Rehabilitation Commission (MRC), the Massachusetts Executive Office of 

Health and Human Services Office of Disability Policies and Programs (ODPP), the 

Massachusetts Department of Mental Health (DMH), and Aging and Disability Resource 

Consortia (ADRC) partners statewide is enhancing the Massachusetts ADRC Options 

Counseling Program by strengthening and refining its current standards to ensure that all 

options counselors throughout Massachusetts have the capacity to serve people with 

disabilities, including mental health and cognitive disabilities, and to make information on 

consumer directed services available to all Options Counseling consumers. This goal will be 

achieved through the following objectives: 1) develop training to expand the ability of Options 

Counseling staff to serve people with disabilities, including mental health and cognitive 

disabilities, and to ensure that Options Counseling incorporates consumer direction, choice 

and dignity of risk; 2) acquire a comprehensive consumer database or interface to track 

Options Counseling services statewide and to facilitate referrals between ADRC partners; 3) 

review, and revise if necessary, current state standards for Options Counseling; 4) monitor 

delivery and impact of Options Counseling; and 5) work with the Administration on Aging 

(AoA) and other grantees to develop national Options Counseling standards. Outcomes will 

include: 1) improved capacity to facilitate consumer direction and serve people with a range 

of disabilities; 2) improved capacity to track referrals and outcomes of Options Counseling 

program; 3) more efficient system of referrals among ADRC partners; and 4) a set of 

enhanced state standards that will inform development of national Options Counseling 

Standards. 








P.O. Box 30676 

Lansing, MI 48909- 8176 

Contact: 

Peggy Brey 

Tel. (517) 241-0988 

Email: breyp@michigan.gov 



Fiscal 

Year 

Funding 

Amounts 









Total $500,000 

Michigan’s goal is to: ensure high quality, unbiased, person-centered, and consistent options 

counseling (OC) will be the experience of individuals desiring assistance with long term care 

(LTC) supports and services regardless of age, disability, income, geography or place of 

residence. Michigan’s OC is guided by standards, policies, and procedures. OC standards 

will be piloted with four ADRC partners who have achieved the designation of “Emerging 

ADRC Partnership” by the Office of Services to the Aging (OSA). Partnerships will participate 

in collaborative learning sessions. Based on the Institute for Healthcare Improvement 

Collaborative Model for Achieving Breakthrough Improvement, these sessions are adapted 

for community-based collaborative. The sessions will enable refinement and standardization 

of OC standards as we shift from a “Single Point of Entry” (SPE) model to a “No Wrong Door” 

approach. Objectives include reviewing and modifying existing standards related to core 

competencies; and developing, testing and refining OC training on competencies, policies 

and processes. Software tools will be developed to collect accurate, consistent data for 

project management, CQI and outcome evaluation within the partnerships. Evaluation 

instruments developed and used in prior Michigan LTC reform initiatives will be refined and 

implemented, including piloting new approaches to ensure standardization among the 

ADRCs through the implementation of quality management systems (QMS). Data elements 

to track participant outcomes and measure quality will be identified. A second goal is to work 

collaboratively and share products with nationwide partners to develop minimum national OC 

standards. Grant products include: statewide standards for OC, OC training curriculum, 

participant and staff surveys, and a software tool. 




Project Title: New Hampshire Aging and Disabilities Resource Center (ADRC) 

Options Counseling and Assistance Program 




Institute for Health Policy and Practice 

51 College Road, Service Bldg. 

Durham, NH 03824-3585 

Contact: 

Susan Sosa 

Tel. (603) 862-4848 

Email: susan.sosa@unh.edu 


Fiscal 

Year 

Funding 

Amounts 









Total $500,000 


New Hampshire (NH) has successfully implemented professional standards for Long Term 

Supports Counselors and has been a leader in designing a person-centered approach to 

long-term care options counseling. Through this proposed project, the University of New 

Hampshire (UNH) Institute on Health Policy and Practice will work collaboratively with the NH 

Bureau of Elderly and Adult Services, the ten local ServiceLink Resource Centers (SLRC), 

and the UNH Institute on Disability to expand and improve the quality of services to SLRC 

participants statewide by strengthening and enhancing person-centered options counseling 

across all programs that provide supports through the SLRC network. This project will 

develop a comprehensive set of standards for Person-Centered Options Counseling; 

implement these standards that provide options counseling for staff through the SLRC 

network; develop and implement statewide training in person-centered options counseling; 

implement quality improvement; evaluate the project’s effectiveness; and participate in the 

collaborative process to develop national standards. 




Project Title: New Mexico Aging and Disability Resource Centers (ADRC) Options 

Counseling and Assistance Standards and Expansion 



New Mexico Aging and Long-Term Services Department 

Consumer and Elder Rights 

2550 Cerrillos Rd. 

Santa Fe. NM 87505-3260 

Contact: 

Carlos Moya 

Tel. (505) 476-4577 

Email: carlos.moya@state.nm.us 

AoA Project Officer: 

Fiscal 

Year 

Funding 

Amounts 









Total $500,000 


The New Mexico Aging and Long-Term Services Department’s (NM ALTSD) Aging and 

Disability Resource Center (ADRC) is enhancing existing options counseling standards 

(operating procedures, benchmarks, and measures) to support the delivery of services to a 

new population and setting. Through these enhanced standards, ALTSD will support “an 

interactive decision-support process whereby consumers, family members and/or significant 

others are supported in their deliberations to determine appropriate long-term care choices in 

context of the consumer’s needs, preferences, values, and individual circumstances.” Project 

Goals: 1) develop a standardized options counseling and assistance program for those 

individuals who are “screened-out” of the Adult Protective Services system but who are in 

need of long-term support services; and 2) expand the successful options counseling and 

assistance program to the community-based setting through the NM ADRC State Health 

Insurance Program (SHIP) program, and a through a partnership with a Center of 

Independent Living in San Juan County. Project Objectives are: 1) increased access to 

long-term support services; 2) decreased involvement with Adult Protective Services; 3) 

increased community-based access to options counseling; 4) increased person-centered 

discharges to a home and community-based setting; 5) increased access to ADRC functions 

by private pay and Medicare/Medicaid (duals) recipients; 6) increased functional abilities - 

Instrumental Activities of Daily Living (IADLs) and (Activities of Daily Living (ADLs)); 7) 

decreased long-term care system cost; and 8) increased use of person-centered long-term 

care planning tools. 




Project Title: Development of Training and Implementation of Standard 

Operating Procedures for Options Counseling and Assistance for 

North Carolina Aging and Disability Resource Centers (ADRCs) 




Long Term Services and Supports 

2001 Mail Service Center 

Adams Building, 101 Blair Dr. 

Raleigh, NC 27699-2001 

Contact: 

Sabrena Lea 

Tel. (919) 855-4428 

Email: Sabrena.Lea@dhhs.nc.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $523,500 


The North Carolina (NC) Department of Health and Human Services (DHHS) is administering 

this two year project for the “Aging and Disability Resource Centers (ADRCs) Options 

Counseling and Assistance Program.” In North Carolina, ADRCs are named Community 

Resource Connections for Aging and Disabilities (CRCs). Project Stakeholders include 

disability and aging partners, academia, consumers, and DHHS divisions and are assisting in 

implementation of the project’s goals and objectives. Project goals are: 1) ensure that the 

service is delivered comparably to the national standard; 2) refine NC’s definition consistent 

with a decentralized CRC model; 3) ensure incorporation of person-centered thinking 

practices and the needs of both aging and disabilities populations; and 4) ensure that local 

CRC partners are well-trained and certified to provide this service. Objectives are: 1) 

develop NC-specific operating procedures and standards including training requirements; 2) 

develop a comprehensive training curriculum; 3) implement standards and training for 

partners in two NC CRCs within the first grant year and for all NC CRCs by month eighteen; 

4) execute evaluation plans that measure training effectiveness and consumer satisfaction 

with the service; and 5) collaborate to develop national standards. Project outcomes include: 

1) certification process for NC CRC partners providing Options Counseling and Assistance; 

2) 15% post-testing improvement for participants trained with the new curriculum; and 3) 90% 

agreement by consumers receiving Options Counseling and Assistance from certified 

counselors that this service met their needs. 




Project Title: Oklahoma's Aging and Disability Resource Center (ADRC) Options 

Counseling and Assistance Program 



Oklahoma Department of Human Services 

Aging Services 



Contact: 

Zachary Root 

Tel. (405) 522-3121 

Email: zachary.root@okdhs.org 


Fiscal 

Year 

Funding 

Amounts 









Total $500,000 


The grantee, Oklahoma Aging Services Division, supports this two-year ADRC Options 

Counseling (OC) standards project. The goal is to improve the delivery of OC by establishing 

standards. The project includes four objectives: 1) establish standards for staff development, 

quality assurance, resource identification, information management systems, and protocols 

for OC; 2) develop and design standardized curricula and tools for the newly developed 

standards; 3) implement trainings on new standards; and 4) collaborate with states and 

stakeholders to produce minimum national standards for OC. The standards will include 

information about existing long-term services and support options, Medicare benefits and 

options, and planning for individuals, which will minimize confusion, enhance individual 

choice and support informed decision-making for consumers. The OC program will serve 

seniors age 60 and older and adults of any age with a physical or developmental disability, 

regardless of personal resources. Training and certification requirements will be included in 

the standards to ensure counselors are prepared to serve target populations. The standards 

also will provide a management system that supports the functions of the ADRC, including a 

mechanism to track client intake, to assess needs, to develop care plans, and to analyze 

utilization and costs. Currently there are a number of contracts and Memoranda of 

Understandings in place; key among them is the Oklahoma Health Care Authority (OHCA), 

Oklahoma’s Medicaid Agency. During much of the first year, OPRS and ASD will be working 

closely together to develop an overall Evaluation Plan for the standards. The Evaluation Plan 

utilization will occur in the second year. 




Project Title: Options Counseling and Assistance Program 



Oregon Department of Human Services 

Seniors and People with Disabilities 

676 Church Street NE 

Salem, OR 97301-1074 

Contact: 

Elaine Young 

Tel. (503) 373-1726 

Email: Elaine.Young@state.or.us 


Fiscal 

Year 

Funding 

Amounts 









Total $500,000 


Aging and Disability Resource Centers (ADRC) are operational in three Area Agencies on 

Aging and Disabilities. An Options Counseling (OC) curriculum for both options counselors 

and their supervisors is being developed and evaluated; a new public-facing website, online 

resource database, and a client contact module will be installed this summer. A strategic 

plan for implementing ADRCs statewide is in process. Oregon is at a critical juncture to 

standardize the delivery of OC services and at present each ADRC is using different 

credentials and staffing ratios to predict OC services. Without mandated statewide 

standards, ADRC consumers will be at risk for receiving services that are dependent on local 

variations in program planning, budgeting, and organizational cultures. To ensure that 

consumers receive the same quality, competency-based services regardless of location, 

project partners are addressing the following goals and objectives: 1) develop standards to 

support OC best practices by systematically identifying core components of six OC 

competencies, personal characteristics needed to perform successfully as an OC, personal 

characteristics needed to perform successfully as a supervisor of OC, and by developing 

state-level tools to implement practice standards for OC; 2) implement new practice 

standards for OC and their supervisors in three ADRCs by assessing competency, revising 

training, and conducting a process evaluation; and 3) identify consumer outcomes of OC by 

interviewing consumers and reviewing client contact data. Outcomes across all goals include 

competency-based practice standards, job descriptions, performance evaluation tools, OC 

staff who meet standards and are well supported by supervisors, and tools for assessing 

consumer outcomes. 




Project Title: Vermont's Options Counseling Standards Project 



Vermont Department of Disabilities, Aging and Independent Living 

State Unit on Aging 

Weeks Building, 103 South Main Street 

Waterbury, VT 05617-16t01 

Contact: 

Merel T. Edwards-Orr 

Tel. (802) 241-4496 

Email: merle.edwards-orr@ahs.state.vt.us 


Fiscal 

Year 

Funding 

Amounts 









Total $498,733 


The Vermont Department of Disabilities, Aging and Independent Living (DAIL) is developing 

and implementing Options Counseling standards statewide across its Aging and Disability 

Resource Connection partner agencies. The Options Counseling standards will build upon 

the efforts of two Area Agency on Aging (AAA) partner agencies who initiated Options 

Counseling and decision support as part of their participation in the Community Living 

Program grant in 2007-2009. Project objectives: 1) develop and implement Options 

Counseling standards across the ADRC partner agencies including the five AAAs, the 

Vermont Center for Independent Living, and the Brain Injury Association of Vermont; 2) 

develop and implement supervisor training and peer mentoring to implement the standards at 

the agency level; 3) provide training on the new standards across the ADRC Options 

Counseling staff statewide; 4) study the capacity of and make needed improvements in 

existing management information systems to conduct desired data tracking, evaluation, and 

quality improvement activities for both State and federal reporting purposes; 5) evaluate the 

experience and impact of the new Options Counseling standards on ADRC partner agency 

staff, consumers/key stakeholders, and on key outcomes and indicators; and(6) actively 

participate in a national discussion that will define and promote national standards across all 

ADRCs. Project outcomes: 1) ADRC partner agencies incorporate statewide Options 

Counseling standards into their ongoing operations and quality improvement structures; 2) 

Options Counseling staff and supervisors are fully trained in Options Counseling standards; 

and (3 individuals seeking long term services and supports receive consistent, high quality 

decision support in a person‐centered manner supporting informed choice. 





and Assistance Programs 



Virginia Department for the Aging 


Richmond, VA 23229-5009 

Contact: 

Katie Roeper 

Tel. (804) 662-7035 

Email: Katie.roeper@vda.virginia.gov 



Fiscal 

Year 

Funding 

Amounts 









Total $503,213 

The Virginia Department for the Aging, together with sister state agencies, The Partnership 

for People with Disabilities, and Area Agencies on Aging and Centers for Independent Living 

within No Wrong Door/Aging and Disability Resource Center (NWD/ADRC) regions are 

working together to: 1) develop statewide Options Counseling (OC) standards for Virginia’s 

ADRCs reflecting equal perspective from aging and disability communities by involving key 

stakeholders, documenting current best practices, identifying strengths unique to service 

provider groups, establishing common language/definitions, identifying challenges to 

remaining or returning to home/community and establish OC protocols accordingly; defining 

roles for families/caregivers when appropriate and developing OC goals and related action 

steps; 2) implement statewide OC standards in 7 ADRC regions and train all ADRCs 

statewide on OC standards by expanding OC capacity using a co-employment model, 

developing curriculum for universal OC training; delivering OC training statewide, defining 

tangible outcome measures and evaluate OC implementation; 3) developing common 

assessment tools for OC and measures for evaluation across providers and target 

populations; integrating measures and tools into ADRC IT system; developing an evaluation 

plan; conducting business practice and outcomes evaluation; and 4) contributing to 

development of national OC standards, documentation of best practices and lessons learned; 

learning from other states; and working collaboratively to develop national standards 

development. As a result, OC practices, tools, and measurements will be standardized; 

ADRC regions statewide will be trained in OC; ADRCs’ capacity to deliver OC will be 

expanded; ADRC regions will be better prepared to serve target populations; and individuals 

will make better-informed, long-term support choices. 




Project Title: Development, Implementation and Evaluation of Options 

Counseling Standards for Aging and Disability Resource Centers 

(ADRCs) in Wisconsin 




Long Term Care 

1 W. Wilson St. 

PO Box 7850 

Madison, WI 53707-7850 

Contact: 

Maurine Strickland 

Tel. (608) 266-4448 

Email: maurine.strickland@wisconsin.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $472,707 


The Wisconsin Department of Health Services is developing, implementing and evaluating 

options counseling standards for Aging and Disability Resource Centers (ADRCs). Our goal 

is to help people make good decisions about their long term care needs with ADRC options 

counseling services. Our objectives are to develop state standards and contribute to the 

development of national standards for options counseling. Wisconsin’s standards have 

focused on contract requirements, knowledge and skills, and best practices. With this 

project, we are taking our standards to a higher level by developing an online manual of 

standard operating procedures, decision support tools, and more specific training for ADRC 

staff. We are applying our 12 years of experience in developing and operating ADRCs and 

lessons from in-depth evaluations of ADRC information and assistance and options 

counseling services. ADRC state staff, practitioners, customers and other interested 

stakeholders, and our evaluation and training consultants are contributing to this process. 

The expected outcomes are ADRC staff with a clear understanding of what options 

counseling entails and how it should be done; staff trained on the new standards and 

procedures; performance measures that permit supervisors and state program staff to gauge 

the extent to which effective options counseling has taken place, and an evaluation that leads 

to refinement of the state’s requirements and informs the national standards development. 

The products will include the standards, evaluation, final report and all other key deliverables 

identified in the grant announcement. 


Aging and Disability Centers – Evidence Based Care Transition Programs 

The Administration on Aging (AoA) held a FY2010 grant competition in collaboration with the 

Center for Medicare and Medicaid Services (CMS) FY2010 to support projects that 

strengthen the role of ADRCs in Evidence-Based Care Transition Models that integrate the 

medical and social service systems to help older individuals and those with disabilities remain 

in their own homes and communities after a hospital, rehabilitation or skilled nursing facility 

visit. AoA has collaborated with (CMS) in support of ADRC programs in 54 States and 

Territories since 2003, through a variety of programs including AoA’s Title IV Discretionary 

Grants Program, the CMS Real Choice Systems Change and Money Follows the Person 

Grant Programs. 

The projects awarded under this competition will demonstrate how ADRCs can play a pivotal 

role in life transitions of older adults and adults with disabilities to ensure that people end up 

in the settings that best meet their individual needs and preferences, which is often in their 

own homes. They will show how ADRC staff can be present at these critical points to provide 

individuals and their families with the information they need to make informed decisions about 

their service and support options, and to help them to quickly arrange for the care and 

services they choose 

Additional Information about AoA’s support of ADRC programs may be read on its website: 



Program: Aging and Disability Centers – Evidence-Based Transition Models 

Grant Number: 90CT0171 

Project Title: California Care Transitions Enhancement Project 



California Health and Human Services Agency 

1600 9th Street room 460 


Contact: 

Karol Swartzlander 

Tel. (916) 651-6693 

Email: KSwartz2@chhs.ca.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $214,741 


Four California Aging and Disability Resource Connection (ADRCs) programs are 

implementing the Care Transitions Intervention (CTI) in Riverside, Orange, San Francisco, 

and San Diego. Early data from the sites underscore the need to reach out and present the 

CTI to underrepresented communities. In response to these findings, California seeks to 

expand the current ADRC CTI program, with the goal of improving the care transitions 

experience and hospital readmissions among diverse and underserved communities at all 

four ADRCs. Objectives for the expanded project are: 1) to identify diverse and underserved 

communities at each ADRC; 2) to develop and implement strategies to reach these patient 

populations; 3) to maintain a robust ADRC CTI Learning Community to share best practices; 

4) to master train ADRC Transition Coaches in CTI; 5) to develop four ADRC business cases; 

and 6) to secure additional financial support for the transition coach positions. Expected 

Outcome include: 1) increased CTI participation from identified diverse and underserved 

communities by 30% at Riverside and Orange ADRCs - baseline to be determined; total 

annual CTI patient target number per site is 100; 2) increased patient confidence and 

capacity in the CTI’s four pillars; 3) improved hospital readmission rates for patients with 

chronic conditions; 4) improved critical pathways between hospitals and ADRCs; and 5) 

project sustainability through secured financial support from partner hospitals and other 

organizations that benefit from reduced hospital readmissions and reduced medication errors. 

Products from this project are: outreach strategies to diverse and underserved patients, four 

ADRC CTI business cases, and a final report. 




Project Title: Coordination and Continuation of the Care Transitions 

Program in Mesa County 



Colorado Department of Human Services 



Denver, CO 80203-1714 

Contact: 


Tel. (303) 866-2696 



Fiscal 

Year 

Funding 

Amounts 









Total $199,388 



Health Care Policy and Financing (HCPF) are conducting a two-year grant for the 

continuation of transitional care improvement in Mesa County’s Aging and Disability 

Resource Center (ADRC) known in Colorado as Adult Resources for Care and Help (ARCH). 

Mesa County was a participant community in Colorado’s Quality Improvement Organizations 

(QIO), the Colorado Foundation for Medical Care (CFMC) Transitions of Care pilot project. 

The primary goal of a transitions coaching program is to increase effective self-management 

capacity of people following a hospitalization and to reduce unplanned re-hospitalizations. 

The objectives are to: 1) standardize and formalize the coaching processes first introduced in 

2007; 2) measure decrease for hospital readmission rates at 14-days, 30-days, 60-days, 90 

days; 3) formalize the Care Transitions Taskforce structure as a subcommittee to the Quality 

Health Network’s Quality Oversight Committee; and 4) over the two-year project serve and 

coach 800 patients. 




Project Title: Connecticut's Aging and Disability Resource Center 

Evidence Based Care Transitions Program 







Contact: 

Jennifer Throwe 

Tel. (860) 424-5862 

Email: Jennifer.Throwe@ct.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $193,418 


Connecticut Department of Social Services, State Unit on Aging, North Central Area Agency 

on Aging, Independence Unlimited and Connecticut Community Care, Inc. are continuing to 

partner to strengthen Connecticut’s North Central Aging and Disability Resource Center 

(NCADRC). The grant strengthens Connecticut’s existing NCADRC Care Transition 

Intervention (CTI) pilot program with the Hospital of Central Connecticut (HCC) via the 

NCADRC. Two Connecticut ADRC representatives will attend national meetings for care 

transitions. The goal is to reduce unnecessary hospital readmissions using the personcentered 

CTI model of hospital discharge, administered at HCC via the NCADRC that is 

capable of including assessment, information, assistance and streamlined access to public 

and privately funded long-term services and supports. Objectives: 1) formally expand the 

HCC CTI pilot to the Southington campus; 2) expand eligible CTI diagnoses to include 

Diabetes; 3) develop greater symbiotic connection between work of NCADRC Community 

Choices Counselors (CCCs) and Care Transition Coaches (CTCs) and add 1 new CCC and 

CTC; 4) introduce Chronic Disease Self Management Program to post-CTI participants; 5) 

improve ADRC MIS capabilities for CTI; 6) strengthen CTC’s CTI training; 7) develop 

program evaluation; and 8) connecting providers throughout the healthcare system to enable 

safe and effective transition of patients. Expected Project Outcomes include: Coleman 

recognized CTC staff training; formal program evaluation by University of Connecticut Center 

on Aging; expanded MIS tracking capabilities; 2 percent reduction in unnecessary HCC 

hospital readmissions; cohesive ADRC workflow relationship between CTCs and CCCs; 

expanded CTI program; CTI consumer Ambassadors; and increased project partnerships 

including Connecticut’s Quality Improvement Organization, Qualidigm. 




Project Title: Florida Aging and Disability Resource Center Evidence-Based 

Care Transition Project 






Contact: 

Jay Breeze 

Tel. (850) 414-2338 

Email: Breezej@elderaffairs.org 



Fiscal 

Year 

Funding 

Amounts 









Total $193,778 

The Florida Department of Elder Affairs, the designated State Unit on Aging, proposes to 

employ grant funding to expand the existing Evidence-Based Care Transitions Intervention 

(CTI) model of E.A. Coleman, MD, MPH, and associates, in Planning and Service Area (PSA) 

7 (Metro Orlando and surrounding areas). The project will operate in Orange, Osceola and 

Seminole counties. Key project partners will be the Senior Resource Alliance, the designated 

PSA 7 Area Agency on Aging and Aging and Disability Resource Center (ADRC), and Florida 

Hospital. The Alliance administers the current CTI program in three Florida Hospital 

community facilities. The goal of the proposed project is to expand program services to three 

additional facilities, for a total of six project sites. The project outcome is to demonstrate the 

capacity of the CTI project to reduce the incidence of re-hospitalizations of project patients as 

compared with Florida Hospital discharges of patients who do not participate in the project. 

Project objectives are: 1) producing key grant deliverables; 2) ensuring program quality; 3) 

effectively using ADRC assets; 4) increasing CTI effectiveness through home and 

community-based services; and 5) expanding the project to new sites. The project targets 

Medicare patients age 60 and older identified as most at risk of hospital readmission. The 

current CTI program and proposed project supplement CTI model services with the provision 

of home and community-based services to support elders in their homes during a 30-day 

recovery period without the need to meet financial eligibility requirements or service 

availability/waiting-list issues. The project’s planned output for the two-year grant period is 

720 enrollments. Project products will include an evaluation plan, formal evaluation tools, 

improved project database and semi-annual/final reports. 




Project Title: Illinois Evidence-Based Care Transitions Project 




421 East Capitol, #100 

Springfield, IL 62701-1799 

Contact: 

Ross Grove 

Tel. (217) 524-7627 




Fiscal 

Year 

Funding 

Amounts 









Total $197,656 

The Illinois Department on Aging (IDOA), in partnership with the suburban Cook County 

Aging and Disability Resource Center (ADRC), Illinois Department of Health and Family 

Services (IDHFS), and the Illinois Department of Human Services Division of Rehabilitation 

Services (IDRS), are overseeing local implementation of the Bridge Program (Bridge). Bridge 

was based on a randomized control trial care transition program: Enhanced Discharge 

Planning Program (EDPP) at Rush University Medical Center (RUMC), and a rigorously 

evaluated program - the Aging Resource Center (ARC), a program of Aging Care 

Connections (ACC). AgeOptions, the Area Agency on Aging/ADRC for suburban Cook 

County and the Progress Center for Independent Living (PCIL) are the coordinating entities 

for this Suburban Cook County region. AgeOptions and PCIL will train Bridge Care 

Coordinators regarding community services for seniors and those with disabilities in order to 

improve hospital care transitions. The primary goals of this grant are: 1) to expand existing 

ADRC transitional care services to 600 disabled individuals under age 60 and vulnerable 

adults age 60+ at imminent risk of nursing home placement who are discharged from 

Adventist La Grange Memorial Hospital (ALMH), RUMC, and MacNeal Hospital; 2) to 

implement EDPP protocols to coordinate the connection to PCIL; 3) to facilitate a smooth 

transition back to the community; and 4) to replicate the Bridge at MacNeal Hospital through 

another ADRC partner, Solutions for Care (SFC). ADRC program enhancements will reduce 

re-hospitalizations, promote quality care, enhance communication between health care 

providers and consumers, improve consumer safety, reduce caregiver stress and start time 

for community services, divert consumers from unwanted nursing home admission, and 

reduce emergency department visits. 




Project Title: Indiana Aging and Disability Resource Center Care 

Transitions Project 




Division on Aging 

402 W. Washington St., E442 

Contact: 


Tel. (317) 234-1749 




Fiscal 

Year 

Funding 

Amounts 









Total $198,391 

This grant builds upon the Geriatric Resources for Assessment and Care of Elders (GRACE) 

model, which currently exists at Wishard and the Indianapolis Veterans Administration 

Centers, and integrate the Aging and Disability Resource Center (ADRC) care mangers 

component that will not only complement the GRACE services but also build a stronger 

relationship between veterans and the ADRCs. The goals of this project are: 1) to integrate 

of Central Indian Council on Aging (CICOA) care managers into the hospital discharge 

planning process at the Indianapolis VA and to provide timely, on-site access to 

comprehensive Options Counseling, care management and when appropriate, Preadmission 

Screening; 2) to more effectively coordinate hospital/ADRC planning process to support a 

more complete consumer/family discharge planning process; 3) to support, at the 

consumer’s/family’s option, access to high quality community-based long-term care supports 

with increased discharge to community-based settings and reduced reliance on nursing home 

care; and 4) when a consumer elects to reside in the community, to ensure linkage with 

physicians and other health care supports with a goal of preventing hospital readmission or 

nursing home admission. Key system outcomes are: 1) supporting information to aid in 

replication of the model across the state; 2) a reduction in nursing home admissions and 

long-stay placements, defined as greater than 90 days, and hospital readmissions, measured 

on a per person, admission, and days basis; and 3) an enhanced ADRC program that 

achieves more timely and effective person centered discharge planning and care transitions 

through collaboration with hospital and physician partners. 




Project Title: Maine Aging and Disability Resource Center Evidence-Based Care 

Transition Program 





32 Blossom Lane, 11 State House Stations 

August, ME 04333-0011 

Contact: 

Romaine Turyn 

Tel. (207) 287-9229 



Fiscal 

Year 

Funding 

Amounts 









Total $184,171 


The Office of Elder Services is building upon current partnerships in Southern Maine between 

the Southern Maine Area Agency on Aging (SMAAA) Aging and Disability Center (ADRC) 

(SMAAADRC), the MMC Physician-Hospital Organization (PHO) and MaineHealth’s 

Partnership for Healthy Aging (PfHA) to incorporate ADRC resources and expand the Care 

Transitions Intervention (CTI) to another medical center. The PHO, in collaboration with 

PfHA, has offered the CTI since 2008. SMAAADRC provides direct access for PHO patients 

in York and Cumberland Counties to community resources through the Community Links 

program, a fax referral system from the PHO to SMAA generating a call to the patient 

connecting them with community resources. SMAAADRC proposes to add an ADRC 

Resource Specialist to the CTI Team, expanding the current offerings - CDSMP through the 

Practice Based Model, Community Links and Savvy Caregiver. Goals: 1) strengthen the role 

of the ADRC in the CTI model - enhancing transitions of care between inpatient, primary care 

and community settings; 2) an crease access to the services of the ADRC for patients of the 

PHO CTI; and 3) create a model to disseminate to the other ADRCs in Maine with CTI 

services and nationally. The PHO includes practices in Lincoln and Oxford Counties, served 

by other ADRCs, which could benefit from the approach modeled by SMAAADRC. 

Objectives are: 1) add ADRC Resource Specialist to CTI Team; 2) integrate with the PHO 

Care Management Department; 3) connect patients and families with benefits and community 

resources; 4) reduce hospital readmissions and Emergency Department visits; 5) assist with 

resolution of medication reconciliation issues; 6) provide access to benefits programs and 

assistance with Medicare prescription drug coverage; and 7) low-income subsidy and 

enrollment into plans. 




Project Title: Aging and Disability Resource Center Evidence Based Transition 

Care Project 




Long Term Care Services 



Contact: 

Stephanie Hull 

Tel. (410) 767-1107 

Email: sah@ooa.state.md.us 

AoA Project Officer: Dric Weakly 

Fiscal 

Year 

Funding 

Amounts 









Total $197,660 


The Maryland Department of Aging (MDoA) is collaborating with the Baltimore City Aging 

and Disability Resource Center known as the Maryland Access Point of Baltimore City (MAP) 

and Johns Hopkins Community Physicians (JHCP) to develop an expanded Guided Care 

Program at selected JHCP practices. The internationally recognized Guided Care model 

provides comprehensive health care by physician-nurse teams for people with several 

chronic health conditions, specifically focusing on the 25% of Medicare patients at highest 

risk for using health services heavily. Scientific studies have shown that Guided Care 

improves the quality of care and suggests that it reduces overall health care costs. This 

project is building on Maryland's Person Centered Hospital Discharge Program and the 

Money Follows the Person Demonstration. Under this initiative, a MAP Guided Care nurse 

works within JHCP to develop a plan of cross referrals, training and collaboration between 

the Guided Care Program and MAP. The nurse provides Guided Care support for up to 25 

patients referred by MAP staff. Referrals are individuals who are being discharged from 

hospitals or nursing homes and who are at high risk of readmissions and emergency room 

events. MAP staff and JHCP convene a series of planning and training sessions to establish 

an on-going system for cross referrals and collaboration between JHCP and MAP. 

Satisfaction, morbidity and cost data are being collected to evaluate the feasibility of 

expanding the Guided Care Program into additional MAP jurisdictions. 




Project Title: Navigating Across Care Settings: Choices for 

Successful Transitions 




Program Planning and Management 

1 Ashburton Place, Fifth Floor 

Boston, MA 02108-1516 

Contact: 

Ruth Palombo 

Tel. (617) 222-7512 



Fiscal 

Year 

Funding 

Amounts 









Total $197,661 


The Massachusetts Executive Office of Elder Affairs (Elder Affairs), in partnership with Aging 

and Disability Resource Consortium of the Greater North Shore (ADRCGNS), Massachusetts 

Rehabilitation Commission and MassHealth seeks to implement Navigating Across Care 

Settings: Choices for Successful Transitions (NACS), in order to provide the Care Transitions 

Intervention (CTI) to 300 people with congestive heart failure, chronic obstructive pulmonary 

disease or diabetes. The project will expand community partnerships to bolster CTI's 

effectiveness by connecting participants with peer supports, evidence-based programs and 

Options Counseling. The goal is to expand capacity to promote healthy, successful care 

transitions by: 1) strengthening communications around consumer health issues across 

settings; 2) fostering consumer health self-management; 3) increasing awareness among 

professionals about care transitions; 4) reducing consumer and caregiver stress; and 5) 

reducing hospital re-admissions, preventable hospitalizations, and premature nursing facility 

placements. NACS will retain six trained CTI coaches, enhance agency partnerships and 

develop a formal evaluation in order to gauge these outcomes: 1) lower rates of rehospitalization 

within 30- and 90-day periods; 2) greater consumer and caregiver satisfaction 

and awareness regarding choice, supports and control surrounding health routines and 

regimens; 3) more effective communication between consumers and health providers; 4) 

more positive feeling among consumers about their health and well being; 5) greater 

caregiver confidence in problem solving abilities and ability to cope with stress and manage 

their lives; and 6) integration and awareness of Care Transitions supports into provider 

practice and referral networks. 




Project Title: SLRC Care Transition Specialist Project 




Office of Sponsored Research 

51 College Ave., Service Bldg. 

Durham, NH 03824-3585 

Contact: 

Laurie Davie 

Tel. (603) 862-3682 

Email: Laura.davie@unh.edu 


Fiscal 

Year 

Funding 

Amounts 









Total $218,074 


This project builds on current collaborative work between the New Hampshire (NH) Institute 

for Health Policy and Practice (NHIHPP), the ServiceLink Resource Centers (SLRC), and 

three local hospitals to implement and/or enhance evidence-based models for care 

transitions. Through this project, three SLRCs which are part of the New Hampshire Aging 

and Disability Resource Center (ADRC) network, will work with two care transition models. 

The Better Outcomes for Older Adults through Safe Transitions (BOOST) model is currently 

being implemented at Lakes Region General Hospital (LRGH) in partnership with the Belknap 

SLRC. This work is enhanced through the establishment of a care transition specialist (CTS) 

at the Belknap SLRC, who works directly with LRGH to enhance how the BOOST model 

extends to the community. The Care Transition Intervention (CTI) model is being 

implemented at Cheshire Medical Center- Dartmouth-Hitchcock Keene (CMC-DHK), in 

partnership with Monadnock SLRC; and at Memorial Hospital, in partnership with Carroll 

County SLRC. Both the Monadnock SLRC and Carroll County SLRC have hired a SLRC 

CTS to provide resources for implementing the CTI model in those hospital-SLRC 

partnerships. The primary program goals of the project are: 1) establishment and training of 

SLRC -CTS in three of NH’s ADRCs to serve as the SLRC-hospital liaison for care 

transitions; 2) define and evaluate the relationship of the SLRC CTS with the provider 

organizations in an evidence-based care transition model and; 3) define and evaluate the role 

of the SLRC CTS within the scope of the evidence-based care transition model and among 

SLRC programs (e.g. Information/Referral specialist). 




Project Title: New York State Aging and Disability Resource Centers 

Care Transitions 



New York State Department for the Aging 


Albany, NY 12223-1251 

Contact: 

Gail Koser 

Tel. (518) 473-8422 



Fiscal 

Year 

Funding 

Amounts 









Total $212,485 


The New York State Office for the Aging (NYSOFA) and Albany County New York Connects 

(Aging and Disability Resource Center - ADRC) will expand an existing Evidenced-Based 

Care Transitions Intervention (CTI) that is currently only available to patients enrolled in one 

local health insurance plan. By strengthening existing relationships between New York 

Connects, the Eddy Visiting Nurses Association, Albany Memorial and Samaritan Hospitals 

and Community Caregivers, the partner agencies will continue to provide the CTI program 

and pair a CTI coach with a trained volunteer Community Supports Navigator (CSN) for 90 

days. This enhanced CTI-Plus program will serve eligible older adults from Albany County 

who are being discharged from Albany Memorial and Samaritan Hospitals. Goal: to decrease 

preventable re-hospitalizations and institutionalization among older adults within 90 days of 

discharge by expanding capacity for NY Connects and its partners to provide the Evidenced- 

Based Care Transitions Intervention and fostering patient integration within the continuum of 

home and community based long term care. Objectives: 1) increase availability of the CTI 

model to consumers and caregivers by expanding the targeted populations; 2) develop a CTI- 

Plus model that combines CTI with the CSN program; 3) increase capacity through provision 

of additional training in the CTI model; 4) sustain the CTI-Plus program by working with 

providers and payers to identify ongoing reimbursement; and 5) conduct an evaluation 

involving consumers and caregivers and to support sustainability and replication. Anticipated 

outcomes are: 1) the CTI-Plus program will serve 200 at-risk Albany County residents each 

year; and 2) at least one sponsor will continue to support the program at the close of the 

grant period. Products: An evaluation report and a final report with recommendations. 




Project Title: Care Transition Poject to Utilize Aging and Disability 




Pennsylvania Department on Aging 

555 Walnut St 5th Floor 

Harrisburg, PA 17101-1919 

Contact: 

Jack Vogelsong 

Tel. (717) 3382 

Email: jvogelsong@state.pa.us 



Fiscal 

Year 

Funding 

Amounts 









Total $197,661 

The Pennsylvania Department of Aging/Office of Long Term Living is working with the 

Delaware County Office of Services for the Aging (COSA) to replicate the Transitional Care 

Model (TCM) providing comprehensive discharge planning and assessment along with 

intensive in-home follow-up by advanced practice nurses (APNs) with the Crozer Keystone 

Health System (CKHS). CKHS comprises five hospitals, a comprehensive physician network 

of primary-care and specialty practices. Building upon the current transitional care program 

with CKHS’ Taylor Hospital, COSA assessors are housed at the hospital to identify and 

engage older adults most at risk for re-hospitalizations. The program is expanding to CKHS’ 

Springfield hospital. The project goal is to prevent re-hospitalizations for a minimum of 235 

high risk seniors over two years. APNs monitor patients upon discharge ensuring their needs 

are met in the transition from acute care to community based settings. Objectives are to: 1) 

provide early identification and assessment of patients at risk of readmission to the hospital 

and to avoid nursing home placement for at-risk seniors; 2) provide home visits and daily 

telephone support by an APN for a minimum of two months post-hospitalization; and 3) 

engage in a multidisciplinary approach that ensures continuity of care working with patients, 

caregivers, families, and physicians ensure that all available supportive services are utilized. 

Expected outcomes of the project are: 1) a decrease in re-hospitalizations of at-risk patients 

65+ during the first year and age 60+ during the second year of the project; 2) savings to 

Medicare and insurers due to decreased hospitalizations; 3) long-term savings to Medicaid as 

a result of nursing home diversions; 4) a more timely on-site hospital assessment and 

development of a transition care plan; and 5) on-home visit by an advanced nurse practice 

nurse within 24-48 hours of hospital discharge. A final report and evaluation will be provided 

by the Public Health Management Corporation (PHMC). 




Project Title: Aging and Disability Resource Center Evidence-Based Care 

Transitions Program 




Hazard Building, 74 West Rd. 


Contact: 

Corrine C. Russo 

Tel. (401) 462-0501 


AoA Project Officer: Carolina ryan 


Fiscal 

Year 

Funding 

Amounts 









Total $196,189 

Rhode Island’s (RI’s) Aging and Disability Resource Center (ADRC), THE POINT, serves as 

the virtual front door to government and community services for older adults (aged 60+), 

adults with disabilities (aged 18+), and their families, friends, and caregivers. By providing 

clients with expert resources, referrals, and assistance, THE POINT connects vulnerable 

individuals with life enhancing government and community based programs, helping them 

achieve greater dignity and self-direction. The grantee, the RI Department of Elderly Affairs 

(RIDEA), and its contractor, Quality Partners of RI (Quality Partners), are conducting a two 

year project to spread Quality Partners’ Care Transitions Intervention (CTI) program to the 

ADRC. Quality Partners provides CTI coaching to Medicare fee for service (FFS) 

beneficiaries as part of its three year demonstration project to reduce Medicare readmission 

rates, and RIDEA and Quality Partners are currently collaborating to train ADRC Options 

Counselors in tenets of the CTI model. This project’s goal will be to expand that existing 

partnership to include implementing coaching with THE POINT’s target populations and 

clients in order to reduce hospital utilization and keep clients in the community. The project’s 

objectives are to: 1) hire and deploy 1.25 full time equivalents (FTE) CTI coaches; 2) 

generate awareness about coaching through THE POINT’s marketing, 3) train the Options 

Counselors to include coaching referral in the client intake process, and 4) ultimately, 

maintain an 18 client caseload of high risk RI elders and adults with disabilities. The products 

will include a Final Report that summarizes lessons learned, project outputs and outcomes 

(including readmission rates), and recommendations for sustainability and spread, both 

locally and nationally. 




Project Title: Aging and Disability Resource Center Evidence-Based Care 

Transition Programs (Center for Technology and Aging) 




500 Deaderick Street, 8th Floor, Suite #825 

Nashville, TN 37243-0860 

Contact: 

Cynthia G. Minnick 

Tel. (615) 741-3309 




Fiscal 

Year 

Funding 

Amounts 









Total $198,698 

The Tennessee Commission on Aging and Disability (TCAD) in partnership with the Greater 

Nashville Regional Council (GNRC) that serves as the Area Agency on Aging and Disability 

(AAAD) and the Aging and Disability Resource Center (ADRC) for Middle Tennessee is 

conducting the ADRC Evidence-Based Care Transition Program of the Implementing the 

Affordable Care Act funded by the Administration on Aging (AoA) and the Centers for 

Medicare and Medicaid Services (CMS). The goal of the Care Transitions Intervention (CTI) 

is to reduce rebound incidents to hospitals or other acute care settings for patients with 

identified acute and chronic conditions in order to improve the quality of their lives and reduce 

health care costs. The Objectives are: 1) to increase and coordinate communication and 

support for patients discharged from hospitals; 2) to increase the patient’s transition-specific 

self-management skills including use of medications and appropriate nutrition; 3) to ensure 

that the patient develops and maintains a record of personal health data; and 4) to link acute, 

transitional, long-term services and other needed services to provide continuity of support for 

the patient. The Outcomes include: 1) an improved communication and coordination system 

of support for the patient and his/her family; 2) reduced costs through reduced rebound 

incidents; and 3) increased patient self-management skills. The Products from this project 

include a final report including lessons learned and evaluation results; articles for publication; 

and a cost analysis to identify savings. 




Project Title: Texas Aging and Disability Resource Center Evidence-Based 

Care Transition Program 




701 West 51st Street 

Austin, TX 78751-2312 

Contact: 

Chrisy Fair 

Tel. (512) 438-3011 

Email: christy.fair@dads.state.tx.us 



Fiscal 

Year 

Funding 

Amounts 









Total $197,541 

As a Community Living Program (CLP) contractor for the Texas Department of Aging and 

Disability Services (DADS), the Central Texas Aging and Disability Resource Center (Central 

Texas ADRC) and its partner Scott & White Healthcare (S&WH) have provided the Care 

Transitions InterventionSM (CTI) to eligible CLP consumers and patients at S&WH since 

October 2008. DADS is using this grant funding to significantly increase patient access to 

CTI in Central Texas, as well as foster a long-term plan for dissemination of CTI across 

Texas’ eight additional ADRCs by: 1) expanding access to CTI in the Central Texas region to 

a larger, more diverse group of older adults (and their family caregivers) at S&WH, and 

implementing CTI at a second hospital (Metroplex Hospital, Killeen, Texas); 2) providing CTI 

training to Central Texas ADRC partner agencies to increase the number of certified 

transition coaches who will provide CTI to a broader, more diverse population of consumers 

and family caregivers; and 3) conducting CTI training for the statewide network of Texas 

ADRCs, including best practice strategies and tools for CTI implementation. DADS will 

support this expansion project by: 1) strengthening its partnership with the Texas Quality 

Improvement Organization (Texas Medical Foundation Health Quality Institute) to promote 

connections between Texas ADRCs and their local hospital systems; 2) facilitating training 

and implementation opportunities for CTI across the Texas ADRC network; and 3) supporting 

hospital re-admission rate data collection efforts in order to promote the adoption of CTI by 

hospitals partners in existing ADRC regions. 




Project Title: Washington State Aging and Disability Resource Center Evidence 

- Based Care Transitions Program 




Aging and Disability Services Administration 


Lacey, WA 98503 

Contact: 

Susan L. Shepherd 

Tel. (360) 438-8633 

Email: Susan.Shepherd@dshs.wa.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $160,517 


Washington State Department of Social and Health Services-Aging and Disability Services 

Administration (DSHS-ADSA), supports this two year Aging and Disability Resource Center 

(ADRC) Evidence-Based Care Transition project in collaboration with one regional Quality 

Improvement Organization (QIO), the Care Transitions Program, two Area Agencies on Aging 

(AAAs), Insignia, and four hospitals. The goal of the project is to establish an ADRC Care 

Transitions Intervention Model in Washington State for eventual statewide expansion. The 

approach is to build on the current CMS-funded Care Transitions Intervention (CTI) Model in 

Whatcom County to formalize the ADRC role, increase ADRC capacity to facilitate care 

transitions; and to develop a template for building additional care transition partnerships in 

Washington State. The objectives are to: 1) formalize the ADRC role in the current 

Whatcom County CTI model; 2) expand use of the ADRC CTI model within the same service 

area; 3) provide training and implement lessons learned to an additional ADRC; 4) apply 

continuous quality improvement and evaluation; and 5) disseminate project information. The 

expected outcomes of this ADRC Care Transition project are: 1) Increased ADRC capacity 

and reach with hospitals in the identified counties; 2) Improved re-hospitalization rates for 

participating hospitals; 3) improved health, chronic conditions self management, by CTI 

participants; and 4) evidence of improved efficiencies and/or cost savings by end of project. 

The products from this project will be: state care transitions data collection requirements; an 

ADRC CTI evaluation plan; an ADRC CTI implementation toolkit; semi-annual reports; and a 

final report. 


Alzheimer’s Disease Supportive Services Program (ADSSP) 

The Administration on Aging held three grant competitions in FY2010 under the Alzheimer’s 

Disease Supportive Services Program (ADSSP); two to expand the adaptation of evidencebased 

programs and one to support new innovations in support of individuals with 

Alzheimer’s disease and related disorders (ADRD) and family caregivers. Congress created 

the ADSSP to encourage states to develop models of assistance for persons with ADRD and 

their family caregivers, and to encourage close coordination and incorporation of those 

services into the broader home and community-based care systems. A number of promising 

practices have been developed Under this and other federal grant programs. States must 

implement community-level projects under this program announcement, and approximately 

75% of the federal grant funds must be spent on community-level activities. 

ADSSP was established in 1991 under Sec. 398 of the Public Health Service Act (P.L. 78 

410) as amended by the Home Health Care and Alzheimer’s Disease Amendments of 1990 

(PL 101-557). Congress transferred the administration of the program to AoA in 1998 

recognizing the need to ensure coordination with other programs for older Americans by its 

passage of the Health Professions Education Partnerships Act (PL 105-392). The ADSSP 

program has proven successful in targeting service and system development to traditionally 

underserved populations, including ethnic minorities, low-income, and rural families coping 

with Alzheimer’s disease and related disorders. 

Additional Information about ADSSP may be viewed on the AoA website: 

http://www.aoa.gov/AoARoot/AoA Programs/HCLTC/Alz Grants/index.aspx 


Alzheimer’s Disease Supportive Services Program: Evidence-Based 

Programs 

The Administration on Aging (AoA) held two grant competitions in FY2010 under the 

Alzheimer’s Disease Supportive Services Program (ADSSP) to demonstrate how existing 

evidence-based service interventions that help people with Alzheimer’s disease and related 

disorders (ADRD) remain in the community can be translated into effective programs 

administered at the community level through the Aging Network and partner organizations. 

Projects funded under this competition were awarded as cooperative agreements to 

demonstrate how the New York University Caregiver Intervention (NYUCI), Resources for 

Enhancing Alzheimer’s Caregiver Health Intervention (REACH II) and Savvy Caregiver 

Interventions, that help family caregivers of persons with Alzheimer’s Disease and Related 

Disorders (ADRD) can be translated into effective programs at the community-level. 

The eleven (11) awardees under this competition are expected to translate research 

interventions with fidelity to the major program design elements that were included in the 

original study or a related subsequent randomized controlled trial. 

Additional Information about ADSSP awards made under this competition, and awards made 

under the FY2010 ADSSP Innovation and Evidence-Based Caregiver Intervention Programs 

beyond the project descriptions in this compendium may be viewed on the AoA website: 

http://www.aoa.gov/AoARoot/AoA Programs/HCLTC/Alz Grants/index.aspx 


Program: Alzheimer’s Disease Supportive Services – Evidence Based Programs 

Grant Number: 90AE0345 

Project Title: Florida 2010 Alzheimer’s Disease Supportive Services Program – 

Evidence-Based Caregiver 




4040 Espanade Way, Suite 315 


Contact: 

Christine R. Kucera 

Tel. No. (850) 414-2060 

Email: Kucerac@elderaffairs.org 

AoA Project Officer: Jane A. Tilly 


Fiscal 

Year 

Funding 

Amounts 









Total $500,000 

The Florida Department of Elder Affairs’ (DOEA’s) goal is to increase the well being of 

caregivers of people with ADRD through the use of the New York University Caregiver 

Intervention (NYUCI). The project will be referred to as the Sarasota Caregiver Counseling 

and Support Program (SCCSP). SCCSP will be implemented by the Jewish Family and 

Children’s Service of Sarasota-Manatee (JFCS) in partnership with Sarasota Memorial 

Hospital’s Memory Disorder Clinic. Special populations that will be targeted include lowerincome 

individuals who cannot afford to pay for professional services, families of military 

veterans, and families from minority populations. The project has five major objectives: 1) 

improve caregiver well being and remove hindrances to the activities required to be effective 

caregivers; 2) reduce depressive symptoms to improve caregiver well being and 

effectiveness; 3) increase the supports caregivers receive from family and friends to improve 

their personal well being and enable them to be more effective caregivers; 4) provide 

caregiver education about care partners’ memory loss and behaviors; and 5) provide 

individual and family counseling. Anticipated outcomes are: 1) maintained caregiver physical 

health; 2) improved caregiver mental health; 3) increased caregiver social support networks; 

4) increased caregiver understanding of memory loss and behaviors; and 5) increased length 

of time between enrollment and nursing home placement of the care recipient. Products will 

include a report describing key findings and lessons learned from the project that can be 

used to replicate the project in other states/communities, a manual for replication, a cost 

analysis, semi-annual data reports, and at least one article for publication in a peer-reviewed 

journal. 


Program: Alzheimer’s Disease Supportive Services – Evidence Based 


Project Title: Georgia Care Consultation Project 



Georgia Southwestern State University 

Rosalynn Carter Institute 

800 GSW Drive 

Americus Drive, GA 31709-4376 

Contact: 

Leisa R. Easom 

Tel. No. (229) 928-1234 

Email: leasom@canes.gsw.edu 

AoA Project Officer: Michele Boutaugh 

Fiscal 

Year 

Funding 

Amounts 









Total $500,000 


The Rosalynn Carter Institute on Caregiving, in collaboration with Georgia Department of 

Aging, Georgia Alzheimer’s Association, three Area Agencies on Aging and the Benjamin 

Rose Institute will replicate the Cleveland Alzheimer’s Managed Care Demonstration (“Care 

Consultation”). The project goal is to implement a proven phone-based care consultation 

intervention for ADRD patients and caregivers in three regions of Georgia and evaluate its 

effectiveness in practice according to the RE-AIM framework. The specific objectives are: 1) 

install and operate the Care Consultation program with fidelity and evaluate its impact on 

ADRD patients, caregivers and the service delivery system, 2) document and analyze the 

process of implementation within each AAA and the Georgia Aging Network, 3) adapt the 

program as necessary in response to ongoing evaluation, 4) assure long-term maintenance 

and continued development of the program in Georgia, and 5) support the adoption and 

implementation of the intervention by others. The outcomes are that caregivers and care 

receivers will report: 1) lower strain, 2) lower depression, 3) increased satisfaction with help 

received, 4) increased rating of quality of care of patient, and 5) fewer unmet 

service/information needs. Anticipated products include a “How-to” manual to support 

implementation of the program by others, presentations at national conferences, articles for 

publication, yearly data reports, a final report; an analysis of program startup and operating 

costs, an analysis of possible cost-offsets including reduced use of health care services, and 

an analysis of client satisfaction and willingness to pay for the Care Consultation service. 




Project Title: Georgia Coastal Resources for Enhancing Alzheimer’s Caregivers 

Health (REACH) 



Georgia Southwestern State University 

Rosalynn Carter Institute 

800 GSW Drive 

Americus, GA 31709 

Contact: 

Leisa R. Easom 

Tel. No. (229) 928-1234 

Email: leasom@canes.gsw.edu 


Fiscal 

Year 

Funding 

Amounts 









Total $418,323 


This project is a collaboration of the Rosalynn Carter Institute at Georgia Southwestern State 

University, The Coastal Georgia Area Agency on Aging (AAA), Georgia Alzheimer’s 

Association and Georgia Unit on Aging Services. The goal of the project is to implement an 

evidence-based, multi-component caregiver intervention in a second region of Georgia, to 

expand its availability in Georgia through the Aging Network, and to evaluate its effectiveness 

in practice according to the RE-AIM (reach, effectiveness, adoption, implementation, 

maintenance) framework. The objectives are: 1) to develop a steering committee and 

implementation team of key stakeholders to provide oversight and facilitate adoption, 

implementation and evaluation of Resources for Enhancing Alzheimer’s Caregivers Health 

(REACH II); 2) to successfully install the program in Coastal Georgia AAA; 3) to fully 

implement the program to serve a minimum of 150 families using the REACH II intervention 

with fidelity and evaluate its impact on participants; 4) to adapt the program as necessary in 

light of evaluation results and real world experience; 5) to assure the long-term maintenance 

and continued expansion of the program in Georgia by creating a REACH II Training Center 

available to all providers in Georgia; and 6) to develop adoption support materials and 

information. Expected outcomes are that Alzheimer’s caregivers: 1) will have reduced 

burden, depression and desire to institutionalize; 2)l be less troubled by memory and 

behavior problems; and 3) have improved social support, health behaviors and self-efficacy. 

Products will be manuals and materials to support implementation, a final report, published 

articles, presentations, an analysis of program startup and operations costs, and semi-annual 

data reports detailing participant demographics, unit of service data, and cost data. 




Project Title: Kentucky's Implementation of Tailored Activity Program: An 

Evidence Based Model 



Kentucky Cabinet for Health and Human Services 

Department for Aging and Independent Living 

275 East Main Street 3E-E 

Frankfort, KY 40621-2321 

Contact: 

Maime Mountjoy 

Tel. No. (502) 564-6930 

Email: Maime.Mountjoy@ky.gov 

AoA Project Officer: Theresa F. Arney 

Fiscal 

Year 

Funding 

Amounts 









Total $228,981 


Kentucky’s Department for Aging and Independent Living (DAIL) is demonstrating the 

Tailored Activity Program (TAP), an evidence based model for improving the delivery of 

services and supports to people with Alzheimer’s Disease and Related Disorders (ADRD) 

and their caregivers. Partners include the Christian Care Communities and the Bluegrass 

Area Agency on Aging and Independent Living to compare outcomes from and established 

Assisted Living Facility and a Medical Model Adult Day Center. The goal is to explore the 

effectiveness of the TAP model in both an assisted living and medical model adult day 

serving older adults suffering from ADRD. The objectives are to: 1) replicate TAP in rural 

regions of Kentucky using National Family Caregiver Support Program; 2) provide detailed 

cost analysis of project in a variety of settings; 3) further evaluate the original study’s findings 

that depressed caregivers effectively engaged in, and benefited from, the interventions; and, 

4) compare the effectiveness of the intervention between the two service settings. The 

outcomes include: 1) decreased agitation or argumentation; 2) increased satisfaction in the 

role as the caregiver; 3) delayed institutional placement for TAP participants; and 4) TAP will 

be demonstrated as a cost-effective alternative to prolong community-based care. The 

products include a final report, including evaluation results; articles for publication; cost 

analysis to support the effectiveness of the Tailored Activities Program; a manual for 

replication of implementation; and abstracts for national conferences. 




Project Title: Maine Savvy Caregiver Project Enhancement 







August, ME 04333-0011 

Contact: 

Romain Turyn 

Tel. No. (207) 287-9214 


AoA Project Officer: Priti Shah 

Fiscal 

Year 

Funding 

Amounts 









Total $421,794 


The Office of Elder Services with Area Agencies on Aging, Maine Alzheimer’s Association 

and the University of Southern Maine - School of Nursing will expand the Maine Savvy 

Caregiver Project (MSCP). The goal of the Maine Savvy Caregiver Project – Enhancement 

(MCSP-E) is to improve the attitude, knowledge and skills of caregivers of people with 

Alzheimer’s Disease and Related Disorders (ADRD) and to increase their confidence, wellbeing 

and self-efficacy. MSCP-E will expand caregiver outreach/involvement in the Savvy 

Caregiver Program (SCP) and develop SCP Part 2 training. The objectives include: 1) 

develop/implement a marketing plan with the Family Caregiver Program (FCP), Aging and 

Disability Resource Centers, state funded Alzheimer’s respite program, the Alzheimer’s 

Association and community programs; 2) embed SCP in the FCP for continuity and 

sustainability; 3) enhance outreach to caregivers by expanding partnerships with the aging 

service system and faith communities, Veteran’s Administration, and education departments; 

4) extend outreach to caregivers of individuals with ADRD earlier in their diagnosis 5) 

develop/implement SCP Part 2 for caregivers completing SCP: and, 6) expand the cadre of 

SCP Master Trainers to include Best Friends trainers. The expected outcomes for 

caregivers include: 1) increased caregiver mastery, competence and coping; 2) improved 

caregiver reaction to care receiver behavior; 3) reduction of caregiver depressive symptoms, 

and 4) improved caregiver mood. The products include reports of key findings, manual(s) to 

implement SCP Part 2, cost analysis to determine the start-up and ongoing operational costs, 

semi-annual data reports, and articles published in peer-reviewed journal(s). 




Project Title: Creating Confident Caregivers: Michigan's Expansion Project 




P.O. Box 30676 

Lansing, MI 48909-8176 

Contact: 

Sally Steiner 

Tel. No. (517) 373-8810 

Email: steiners@michigan.gov 

AoA Project Officer: Shannon Skrowonski 


Fiscal 

Year 

Funding 

Amounts 









Total $262,468 

The Michigan Office of Services to the Aging (OSA) will collaborate with six Area Agencies on 

Aging, Michigan’s Alzheimer’s Association chapters, and aging service providers to 

implement the Creating Confident Caregivers: Expansion Project. The goal is to expand the 

Savvy Caregiver Program (SCP) statewide to reach diverse populations of caregivers by 

extending the program to six additional Area Agency on Aging regions. The objectives 

include: 1) train eligible staff from aging and Alzheimer’s organizations to be trainers; 2) 

provide the program throughout the six additional regions; 3) develop and sustain Master 

Trainers to monitor fidelity monitoring and train other staff/volunteers to expand SCP; 4) 

evaluate the program using RE-AIM; 5) assess SCP’s effectiveness with caregivers using 

participant surveys; 6) assess the cost-effectiveness of caregiver training in various settings; 

7) disseminate project information. The outcomes include: 1) expansion of Michigan’s 

services to dementia caregivers and improvement in caregiver confidence, knowledge and 

skills; 2) enhanced caregiver knowledge, skills, and reduced distress; agencies will increase 

their support of dementia caregivers; 3) embed SCP in the services provided by Alzheimer’s 

and aging services; and 4) AAAs incorporate the SCP into their multi-year area plans. The 

products include a final report on“key findings/lessons learned” using the RE-AIM model; an 

implementation “how-to” manual; cost analysis; and articles for journal publication. 




Project Title: Alzheimer's Disease Demonstration Grants to States 






Raleigh, NC 27699-2101 

Contact: 

Karisa Derence 

Tel. No. (919) 733-0443 

Email: karisa.derence@dhhs.nc.gov 

AoA Project Officer: Shannon Skowronski 

Fiscal 

Year 

Funding 

Amounts 









Total $500,000 


The North Carolina Division of Aging and Adult Services supports this three year grant project 

in collaboration with Area Agencies on Aging, Park Ridge Hospital, Duke Family Support 

Program, University of North Carolina, University of Michigan and other key partners. The 

goal is to replicate and enhance the North Carolina community translation of the evidencebased 

“Resources for Enhancing Alzheimer’s Caregiver Health” (REACH II) intervention for 

feasible, cost-effective and sustainable benefits at the community level. North Carolina 

REACH II will be expanded to new areas of the state through the Aging Services Network 

and partner organizations with the following objectives: 1) to train four new interventionists 

on the REACH II model; 2) to address disparities through outreach to low-income rural and 

minority families caring for a person with dementia at home; 3) to deliver intervention services 

to 21 new counties across eight AAA regions; 4) to ensure fidelity in program implementation 

while adapting it for cultural sensitivity and contextual relevance; 5) to ascertain program 

benefits for targeted populations; 6) to analyze cost-effectiveness in implementation; and 7) 

to build upon the existing infrastructure for sustainability of evidence-based programs in North 

Carolina using the RE-AIM framework. The expected outcomes are: 1) enhanced ability to 

manage depression and burden; 2) improved skills for self-care and healthy behaviors; 3) 

better use of social support networks; 4) reduced risk for care recipients; and 5) increased 

capacity for family care at home. Products will include: a report on key findings and “lessons 

learned”; a revised manual to assist with program replication and integration; and a cost 

analysis. 




Project Title: Ohio's Alzhiemer’s Disease and Related Disorders Expansion 

and Advancement Project 



Ohio Department for the Aging 

50 W. Broad St., 9 th Floor 


Contact: 

Marcus J. Molea 

Tel. No. (614) 752-9167 

Email: mmolea@age.state.oh.us 



Fiscal 

Year 

Funding 

Amounts 









Total $495,939 

The Ohio Department of Aging, in collaboration with regional Alzheimer’s Association 

chapters serving the state of Ohio, area agencies on aging, providers and constituent groups, 

and evaluators from the Benjamin Rose Institute, will expand the Reducing Disability in 

Alzheimer’s Disease (RDAD) program statewide and make program enhancements based on 

20 months of piloting and deploying RDAD in Ohio. The RDAD program developed by a 

research team led by Linda Teri, PhD at the University of Washington provides physical 

conditioning and behavior modification in the home for persons with Alzheimer’s disease and 

their caregivers. The goal is to expand the RDAD program statewide. The objectives are to: 

1) prepare 18 new field trainers; 2) teach over 400 new persons with dementia/caregiver 

dyads; 3) identify and test at least three new program delivery models and/or venues; 4) 

increase the percentage of minority and veteran dyads participating in the RDAD program; 5) 

identify at least three permanent funding streams; 6) replicate outcomes from the original 

research; and 7) offer a model for replication nationally and internationally. The outcomes of 

the project are: 1) increased levels of activity, improved physical health and function and less 

depression among persons with Alzheimer’s disease; 2) successful implementation of 

exercise and behavior modification protocols in the home; and 3) satisfaction and acceptance 

of the program by persons with dementia/Alzheimer’s disease and their caregivers. The 

products from this project will include a final report, with evaluative results; articles for 

publication; a cost analysis detailing start-up and maintenance to support the program; and, 

an implementation manual and training materials for replication. 




Project Title: Alzheimer's Disease Demonstration Grants to States – Evidence 

Based Project 



Utah Department of Human Services 


195 N 1950 W 

Salt Lake City, UT 83116-3097 

Contact: 

Sonnie Yudell 

Tel. No. (801 538-3926 

Email: syudell@utah.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $226,990 


The Utah Division of Aging and Adult Services, in collaboration with the Alzheimer’s 

Association Utah Chapter, Utah State University, the University of Utah, the Veteran’s 

Administration and specific Area Agencies on Aging will replicate the tools and strategies of 

the New York University Caregiver Intervention (NYUCI). The goal is to employ this 

counseling and supportive intervention in a coordinated community-based program to 

improve caregiver well-being among minority, culturally diverse and rural-based populations. 

The objectives are to: 1) expand the evidence base by serving 200 families with the NYUCI 

program; 2) achieve the original NYUCI participant outcomes; 3) demonstrate viability of the 

intervention with minority populations; 4) maintain fidelity with the NYUCI program; 5) embed 

the intervention at sites across Utah. Working with identified multicultural populations, the 

project will achieve the following outcomes: 1) ease in caregiver burden; 2) reduced 

caregiver symptoms of depression; 3) improved caregiver’s stress reaction to problem 

behaviors of the care recipient with dementia; 4) strengthened caregiver social support 

networks; and 5) delay in premature nursing home placement (and/or caregiver resignation to 

placement). Products from this project will include a final report; a “Caring for Your 

Alzheimer’s Loved-One at Home” caregiver manual; a web-based support center on the 

Alzheimer’s Chapter website to which agencies may link and community providers may 

inquire for information on serving multicultural families; abstracts for national conferences; 

research results for publication; and a conference on multicultural competency in counseling 

and dementia care in Utah. 




Project Title: Language Enriched Exercise Plus Socialization in Rural Wisconsin 

Project Period: 09/01/2010- 08/30/2011 



1 West Wilson St. 

Madison, WI 53703-7851 

Contact: 


Tel. No. (608) 267-9719 

Email: kristen.felten@wi.gov 



Fiscal 

Year 

Funding 

Amounts 









Total $332,267 

The grantee, the Wisconsin State Unit on Aging, along with its major community partners 

including the local Aging and Disability Resource Centers, local Agencies on Aging, and the 

University of Wisconsin, support this three year, evidenced-based Alzheimer Disease 

Supportive Services Program grant. The project will translate the Language Enriched 

Exercise Plus Socialization (LEEPS) targeting African American populations, and 

underserved rural population groups. The project goal is to demonstrate the effectiveness of 

the chosen intervention in preserving the abilities of individuals with Alzheimer’s disease and 

related disorders (ADRD), improving family caregivers’ satisfaction with their role and raising 

the level of awareness and understanding of Alzheimer’s Disease in the community. The 

objectives are: 1) to provide people with ADRD opportunities for regular exercise in a safe 

environment, opportunities to socialize and perform meaningful work and the type of cognitive 

stimulation shown to be effective in maintaining cognitive abilities in people with ADRD; and 

2) to provide family caregivers some time off-duty twice per week. The expected outcomes of 

this project are: 1) maintenance of cognitive and functional abilities in persons with ADRD; 2) 

improvement in physical fitness and mood in persons with ADRD; and 3) improved 

satisfaction in family caregivers with their roles a caregiver. The products will be a report that 

describes the project, a manual to guide others in replicating the project, a cost analysis, a 

semi-annual data report and an article for publication in a peer reviewed journal. 




Project Title: New York University Caregivers Intervention in Wisconsin's 

Rural Northwestern Communities 



Wisconsin Bureau of Aging and Disability 

1 West Wilson Street 

Madison, WI 53703-7851 

Contact: 


Tel. No. (608) 267-9719 

Email: kristen.felten@wi.gov 



Fiscal 

Year 

Funding 

Amounts 









Total $329,091 

The Wisconsin State Unit on Aging (SUA), in cooperation with local partners, will oversee this 

project to support the spousal caregivers of people with Alzheimer’s disease or related 

dementia (ADRD) living in rural northwestern Wisconsin. This project will translate the New 

York University Caregiver Intervention (NYUCI). The project goal is to enable sustained 

family caregiving in the community which will lead to delayed nursing home admission for 

individuals with Alzheimer’s disease and related dementias. The objectives of this project 

are: 1) provide continuous individualized caregiver support counseling throughout the 

caregiving relationship; 2) ensure participation in the program is as convenient for the 

caregiver as possible; 3) maximize the impact the project will have in the chosen 

communities; 4) quantitatively demonstrate successful project outcomes; and 5) incorporate 

this successful project into the state aging plan. The expected outcomes of this project are: 

1) spousal caregivers will maintain or improve their physical and mental health; 2) spousal 

caregivers will maintain or improve their satisfaction with providing care to their family 

member; and 3) individuals who are being cared for by spouses will not move into a nursing 

home as soon as they might have without the support of this project. The products will be a 

report that describes the project, the translation process, key findings and lessons learned; a 

manual to guide others in replicating the project; a cost analysis; semi-annual data reporting 

and an article submitted for publication in a peer-reviewed journal. 


Alzheimer’s Disease Supportive Services Program: Innovation Projects 

Twenty-two (22) projects were funded under this Fy2010 competition as cooperative 

agreement State demonstrations for improving the delivery of services and supports at the 

community level to people with Alzheimer’s disease and related disorders (ADRD). State 

agencies submitted applications under one or more of three competition categories: 

- Demonstrations of evidence informed interventions based on interventions that appear to 

have a positive impact on the majority of persons with ADRD and their caregivers. 

- Demonstrations of promising practice indicating that the intervention was likely to have a 

positive impact on the majority of persons with ADRD and their caregivers. 

- Innovations in system redesign that involved examination of current aging, health and longterm 

supportive service systems in order to enhance their ability to serve persons with ADRD 

and their caregivers. 


Program: Alzheimer’s Disease Supportive Services – Innovation Programs 

Grant Number: 90AI0029 

Project Title: San Francisco Dementia Care Network for High Risk Families 



University of California, San Francisco 

School of Nursing 

3333 California Street, Suite 315 

San Francisco, CA 94118-6215 

Contact: 

Patrick Fox 

Tel. (415) 476-5483 

Email: pat.fox@ucsf.edu 


Fiscal 

Year 

Funding 

Amounts 









Total $320,713 


The University of California San Francisco (UCSF), in collaboration with the San Francisco 

Department of Aging and Adult Services (DAAS), the Alzheimer’s Association of Northern 

California, and Kaiser Permanente San Francisco (KP), are implementing The San Francisco 

Dementia Care Network as one component of San Francisco’s Strategy for Excellence in 

Dementia Care, a road map for addressing the expected increase in demand for services 

relating to Alzheimer’s/dementia care between 2010 and 2020. The goal is to develop a 

dementia care network for caregiving families in San Francisco that will improve the ability of 

medical systems to address Alzheimer’s disease (AD) and connect caregivers to needed 

educational and support services. The objectives are to: 1) improve of the quality of 

dementia care by educating staff in best practices and developing an electronic dementia 

care plan system; 2) improve capacity to provide education to families and caregivers of 

members with AD; and 3) proactively connect the caregivers with AD to community-based 

sources of education and support. The expected outcomes are: 1) improvements in the selfefficacy, 

knowledge and skills of dementia caregivers during times of medical, functional or 

caregiving crisis, 2) a decrease in preventable emergency room (ER) visits, hospitalizations, 

physician visits, and post-hospitalization skilled nursing faculty (SNF) days; and 3) a 50% 

increase in utilization of community-based services by caregivers. The products include: an 

electronic dementia care plan system at KP, a report of lessons-learned, a manual that will 

allow other communities to replicate the project, a cost analysis and a semi-annual data 

report. 


Program: Alzheimer’s Disease Supportive Services – Innovative Projects 


Project Title: Client Centered Service for People with Early Stage Alzheimer’s 

Disease and Their Care Partners 



Colorado State University 

Department of Psychology 

202 Campus Delivery 

Fort Collins, CO 80523-2002 

Contact: 

Dr. Paul Bell 

Tel. No. (970) 491-7215 

Email: plubium@lamar.colostate.edu 


Fiscal 

Year 

Funding 

Amounts 









Total $306,424 


The Colorado State University Institute of Applied Prevention Research and the Alzheimer’s 

Association Colorado Chapter (AACC), in cooperation with Area Agencies on Aging, Aging 

and Disability Resource Centers, the State Unit on Aging, and community service providers 

will collaborate to promote and deliver AACC services to families facing early stage dementia. 

The goal is to evaluate satisfaction and well being outcomes for people with early stage 

dementia and their care partners who participate in a self-selected protocol of counseling, 

training, support, and socialization. The objectives include: 1) provide AACC care 

consultation to people with early stage dementia and their care partners as dyads to assist 

with their short- and long-term planning; 2) conduct Early Stage Strategies series (6 contact 

hours) for those dyads who enroll, and maintain as a control group those who do not enroll; 

3) provide additional supportive social and intellectual activities self–selected by participants; 

and 4) evaluate and disseminate the outcomes. Information about participants’ use of AACC 

early stage services and about user well being will be obtained at the initial AACC 

consultation and every three months thereafter. The expected outcomes for dyads include: 

1) increased knowledge of Alzheimer’s disease; 2) recognition of the need for future planning; 

3) enhanced emotional well being as evidenced by an improvement in self efficacy; 4) 

reduction in isolation and depression; and 5) an increased participation in support and social 

activity programs. The products will include a “key lessons learned” summary, a manual to 

guide others in establishing early stage services, and a cost analysis, ADDGS reports, and at 

least one journal article. 




Project Title: Alzheimer's Disease Supportive Services Program: The 

CONNECTIONS Project for Innovative Respite Options 






Contact: 

Margaret Gerundo-Murkette 

Tel. No. (860) 424-5344 

Email: Margaret.Gerundo-Murkette@ct.gov 



Fiscal 

Year 

Funding 

Amounts 









Total $300,000 

The Connecticut Department of Social Services (DSS) is proposing a project in response to 

the “Promising Practices” category of the ADSSP Innovation Programs grant. The goal of the 

CONNECTIONS Project is to allow DSS to partner with key stakeholders in the Alzheimer’s 

service community to offer an innovative respite option and source of support for individuals 

living in the North Central region of Connecticut with Alzheimer’s disease who are at risk of 

Medicaid spend down and/or nursing home placement. The objectives are to: 1) strengthen 

the ADRD referral network through the North Central Connecticut Aging and Disability 

Resource Center (ADRC), the Alzheimer’s Association, the Veterans’ Administration and 

state and federally funded programs such as the Connecticut Homecare Program for Elders, 

the Connecticut Statewide Respite Care Program, and the National Family Caregiver Support 

program; 2) expand the options available to families seeking respite by offering innovative 

cognitive training as an alternate source of respite support; and 3) offer training to caregivers 

on providing care for someone with Alzheimer’s disease and promoting brain health for 

caregivers and care recipients. The expected outcomes are to 1) increase the 

responsiveness and cost effectiveness of the service delivery system through enhanced 

coordination between agencies and existing programs; 2) provide caregivers and individuals 

with ADRD increased awareness of available services and expanded service options; and 3) 

provide highly replicable cognitive training model improving functional status of ADRD 

individuals. Products include a report of key “lessons learned”, project manual, informational 

DVD, cost analysis, semi-annual data report, ADRD Directory of Services, informational 

video, cognitive training DVD, and evaluation results. 




Project Title: DC Office on Aging Alzheimer's Disease Supportive Services 

Therapeutic Innovation Project 




441 4 th St., NW, Suite 900 S 


Contact: 


Tel. No. (202) 724-4382 




Fiscal 

Year 

Funding 

Amounts 









Total $256,146 

The DC Office on Aging (DCOA) is collaborating with Home Care Partners, a nonprofit home 

care agency, along with adult day centers and other providers in our Senior Service Network, 

to train direct care workers and family caregivers in therapeutic engagement/compassionate 

touch (TECT). This innovative therapeutic engagement technique incorporates a 

recreational-based therapy that involves activities to promote and stimulate the social and 

physical functioning of clients, and Reiki, a holistic therapy designed to reduce stress through 

the gentle placement of hands. The goal of the project is to train paid direct care workers and 

family caregivers in TECT. The objectives are to 1) recruit participants through the DCOA 

Senior Service Network agencies; 2) provide training to 64 home care aides and 10-15 family 

caregivers in Year 1 with approximately half of these aides and family caregivers selected to 

receive more extensive Reiki training, taught by a Reiki Master level trainer; and 3) trainees 

will receive follow-up training, and long-term impact will be assessed in Year 2. The 

expected outcomes include reduction in undesirable behavioral symptoms of dementia, 

reduced stress in caregivers, and increased job satisfaction in direct care staff. The products 

will include a video and training manual and reports. 




Project Title: 2010 Alzheimer’s Disease Supportive Services Program 

Innovation 




4040 Esokanada Way, Suite 315 


Contact: 

Christine R. Kucera 

Tel. No. (850) 414-2060 

Email: Kucerac@elderaffairs.org 



Fiscal 

Year 

Funding 

Amounts 









Total $253,539 

The Florida Department of Elder Affairs (DOEA) will partner with Memory Disorder Clinics to 

address the priority area of Early Stage Dementia (ESD) in Central Florida. The program is 

referred to as the Healthy Brain Initiative (HBI). The goals of the program are to provide 

educational programming designed to prolong brain function and independence of the person 

with ESD and to connect both the person with ESD and the care partner with resources and 

support to encourage pro-active planning for future care. The objectives are: 1) Provide early 

detection of cognitive problems such as ESD through free community memory screening available 

from the Memory Disorder Clinics; 2) Provide educational programs on memory enhancement 

training techniques within each of the three Memory Disorder Clinic services areas; 3) 

Create/enhance a monthly educational support group at the three Memory Disorder Clinic 

sites for participants in the memory training class, as well as community participants; 4) Train 

volunteer class facilitators in each of the three Memory Clinic’s service areas. The outcomes 

are to: 1) provide memory enhancement training to individuals with ESD and their care 

partners; 2) have volunteers be able to teach the memory enhancement program; 3) provide 

opportunity for discussion about ESD and future planning with available resource information 

in dual ESD Support Groups for people with ESD and care partners; 4) to train Elder Helpline 

staff of the participating Aging and Disability Resource Centers (ADRCs; and 5) to present 

the program to the state’s Alzheimer’s Disease Advisory Committee and other Memory 

Disorder Clinics to expand the reach of the grant statewide. The products include a final 

report on lessons learned, with specific information on implementation and replication; a 

manual including training tools and marketing materials; a cost analysis including start-up and 

operations costs; and data reports including demographic and unit-of-service data. 


Program: Program: Alzheimer’s Disease Supportive Services – Innovative Projects 


Project Title: Georgia's System's Redesign: New Protocols and Interventions to 

Better Serve Persons with Early Stage Alzheimer's Disease 





Two Peachtree St., 9 th Floor 


Contact: 

Cliff Burt 

Tel. No. (404) 657-5336 

Email: gcburt@dhr.ga.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $300,000 


Georgia’s Department of Human Services (DHS) Division of Aging Services (DAS) is 

collaborating with the Alzheimer’s Association, Georgia Chapter, the Central Savannah River 

Area Agency on Aging, the Coastal Georgia Area Agency on Aging, and the Gerontology 

Center at Georgia State University. The project goal is to re-design state-wide service 

delivery through inter-agency collaboration and the development of new protocols and 

interventions to better serve persons with early stage Alzheimer’s disease (AD) and their 

caregivers. The objectives are to: 1) improve service access for persons with early stage 

AD; 2) refine Georgia’s comprehensive social service assessment to identify people with 

early stage AD; 3) implement/ integrate into the access system multi-faceted interventions for 

persons with early stage AD. The expected outcomes include: 1) improved proficiency of 

Area Agency access services staff and Adult Protective Services intake staff in identifying 

persons with early stage dementia; 2) improved knowledge/understanding by affected 

consumers of AD and its progression; 3) improved ability of affected consumers to plan for 

needed supports/services; 4) improved satisfaction of affected consumers with services, 

supports, interventions; 5) increased ability of community medical practice staff to identify and 

address early stage AD; 6) increased awareness of law enforcement agencies of wandering 

behaviors and driving safety in persons with AD; decrease in caregiver burden; and 7) 

increased length of stay in the community of consumers with early stage AD. Products will 

include screening tools for identifying persons at risk; clinical counseling protocol; improved 

inter-agency referral procedures; training for physicians, service agency staff and law 

enforcement personnel; and development and administration of an evaluation methodology. 




Project Title: Alzheimer’s Disease Supportive Services Program Innovations 

Grant 




3380 American Terrace Suite 120 


Contact: 

Kim Toryanski 

Tel. No. (208) 334-3033 

Email: kim.toryanski@aging.idaho.gov 



Fiscal 

Year 

Funding 

Amounts 









Total $163,393 

The Idaho Commission on Aging is collaborating with the Administration on Aging (AoA), 

National Council on Aging, and other national and state partners to provide the Building 

Better Caregivers program. The goal of the program is to reform and expand Idaho’s long 

term care services and supports (LTSS) system statewide for persons with Alzheimer’s 

Disease and Related Disorders and their caregivers by empowering the Aging and Disability 

Resource Centers through training, community outreach, and implementing and evaluating 

the Building Better Caregivers program. The objectives are to: 1) empower ADRCs by 

training a cadre of facilitators to provide statewide support to persons identified and referred 

by the AAAs through their current Information and Assistance functions; 2) work with 

Alzheimer’s disease and related disorders (ADRD) informed Advisory Councils, staff, and 

providers to deliver targeted outreach messages to caregivers; and 3) increase the 

availability of the program on-line will provide caregivers living in the rural and frontier 

communities across the state with needed support. The outcomes include: 1) better-trained 

caregivers and advocates around LTSS for persons with ADRD and their caregivers; 2) 

expanded visibility of Aging and Disability Resource Centers (ADRCs) as the “no wrong door” 

portal to LTSS with special training in ADRD and caregiver needs; 3) increased utilization of 

appropriate LTSS resources by caregivers through the local ADRC; and 4) expanded direct 

services available to caregivers from every AAA service area. The products will include 

reports, lessons learned, cost analysis, and a manual describing implementation. 




Project Title: Standards for Care for People with Alzheimer's Disease and Related 

Disorders in the Home 



Massachusetts Departent of Elder Affairs 

1 Ashburn Place, 5 th Floor 

Boston, MA 02108-1518 

Contact: 

Joseph Quirk 

Tel. No. (617) 222-7468 

Email: Joe.Quirk@state.ma.us 



Fiscal 

Year 

Funding 

Amounts 









Total $450,000 

The Massachusetts Executive Office of Elder Affairs is implementing a System Re-design of 

its Home Care Program (HCP) to improve quality of services and access to diagnosis, care 

and support for people with Alzheimer's disease and related disorders (ADRD) and their 

family caregivers. The goal is to implement new Standards for Dementia Care for people in 

HCP, which address gaps in assessment, caregiver support, care coordination, provider 

qualifications, and personal care plan standards. The objectives are to: 1) enhance capacity 

of Aging Services Access Point (ASAP) staff to screen for ADRD, particularly early stage; 2) 

reduce stress and improve well-being of family caregivers; 3) improve access of Home Care 

consumers with ADRD to diagnostic services and treatment; and 4) increase availability, 

quality and utilization of services targeted to persons with ADRD. The outcomes are: 1) 

consumers with ADRD will be better able to function in the community; 2) informal caregivers 

will be better able to function in their caregiver role; 3) coordination of care between ASAP 

staff and primary care physicians will be improved; 4) ASAP staff will be better able to identify 

ADRD and associated risks; and 5) providers will be more effective in working with 

consumers with ADRD. Products will include Standards for Dementia Care in the Home Care 

Program, a risk assessment tool for cognitive impairment; a report on lessons learned, a 

manual and cost analysis to help agencies replicate the program, a semi-annual data report, 

guidelines for Occupational Therapy for people with dementia, a replicable training module 

for the direct care workforce. 




Project Title: Alzheimer's Disease Supportive Services Program: Innovation 

Programs to Better Serve People with Alzheimer's Disease 



Missouri Department of Health and Senior Services 

920 Wildwood Drive 

P.O. Box 570 

Jefferson City, MO 65102 

Contact: 

Glenda Meachum-Cain 

Tel. No. (573) 526-8534 

Email: Glenda.Meachum-Cain@dhss.mo.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $275,198 


The Missouri Department of Health and Senior Services (DHSS), four Missouri Alzheimer’s 

Association Chapters, and ten Area Agencies on Aging (AAA’s) propose a two-year 

innovative Alzheimer's Disease Supportive Services Program grant on system re-design to 

increase usage of available services by Missourians with Alzheimer’s disease. Project Learn 

MORE (Missouri Outreach and Referral Expanded) will expand use of the Alzheimer Disease 

(AD-8) screening tool piloted by the 19-county Central Missouri Area Agency on Aging 

(CMAAA) during the Project LEARN and increase referrals to the Alzheimer’s Association 

from other partners including the Veteran’s Affairs (VA) Medical Centers in targeted areas. 

The project goal is to provide a coordinated method to identify and guide those experiencing 

cognitive impairment who have not sought medical evaluation and/or are not fully utilizing 

supportive services and provide them with tools to increase their ability to cope with the 

disease. Objectives are: 1) implement a state-wide use of a formalized identification and 

referral process; 2) develop consumer-directed action plans addressing individual needs, 

minimizing barriers to success and encouraging utilization of supportive services; 3) develop 

an impact analysis related to participant decisions to live at home or in institutions; and 4) 

disseminate project information. Anticipated Outcomes are: 1) use of the AD-8 screening 

tool and referral process will be adopted throughout the ten Missouri AAA’s client assessment 

process; 2) individuals with Alzheimer’s will experience increased sense of ability to utilize 

coping strategies in facing the challenges of Alzheimer’s disease; and 3) increased 

awareness and usage of supportive community and Alzheimer’s Association services. 

Families/individuals served will perceive that services offered and knowledge gained will 

extend the time of remain living in the community. 




Project Title: New Mexico's Alzheimer's Disease Supportive Services Program: 

Innovations Program 



New Mexico Department of Aging and Long-Term Services 

2550 Cerrillos Rd. 


Contact: 

Tracy Wohl, 

Tel. No. (505) 476-4776 

Email: l: tracyw.wohl@state.nm.us 

AoA Project Officer: Jane Tilly 


Fiscal 

Year 

Funding 

Amounts 









Total $290,697 

The goal of the New Mexico (NM) project is to improve the capacity of the state’s home and 

community-based long-term care delivery system to address the needs and issues of 

caregivers of veterans with Alzheimer’s disease and related dementias (ADRD). The NM 

Aging and Long-Term Services Department will partner with New Mexico’s area agencies on 

aging, the NM Chapter of the Alzheimer’s Association, and New Mexico’s primary veteran 

service agencies (the Veterans Affairs Hospital, the NM Department of Veterans Services, 

and the Navajo Department of Veterans Affairs), as well as other aging network partners. 

The objectives are: 1) educate and train NM home and community based long-term care 

services system staff and volunteers regarding the provision of outreach and supportive 

services to caregivers of veterans with ADRD; 2) expand partnerships with the staff of New 

Mexico’s primary veteran service agencies to inform and educate them regarding the 

availability of evidence-based caregiver intervention opportunities, resources and supports; 

and 3) implement evidence-based caregiver interventions for caregivers of veterans with 

Alzheimer’s disease and other dementias. The outcomes include: 1) increased access by 

New Mexican veterans with ADRD and their caregivers to culturally and linguistically 

appropriate interventions that will increase their knowledge, skills, attitudes and abilities to 

handle the challenges of dealing with ADRD, as measured by pre- and post-intervention 

surveys of caregivers; and 2) increased use of support services by New Mexican veterans 

with ADRD. Products include presentations at national conferences, such as the National 

Alzheimer’s Association Conference, the Joint Conference of the American Society on 

Aging/National Council on Aging and the National Home and Community-Based Services 

Conference, and articles to be printed in national publications. 




Project Title: Randomized Trial of University-AAA-State Partnership to Link 

Primary Care Physicians and Aging Service Providers 



University of North Carolina at Chapel Hill 

Carolina Alzheimer's Network 

Manning Drive at 15-501 Bypass 

Chapel Hll, NC 27599-7595 

Contact: 

Dr. Philp D. Sloane 

Tel. No. (919) 966-7173 

Email: psloane@med.unc.edu 


Fiscal 

Year 

Funding 

Amounts 









Total $326,638 


This project is an expansion based on a partnership between the university-based Carolina 

Alzheimer's Network (CAN), two Area Agencies on Aging, and the North Carolina Division of 

Aging and Adult Services. The goal of this grant is to determine whether this project should 

be continued and replicated by generating scientific evidence that examines patient 

outcomes. A randomized trial will be used to evaluate this promising practice. The objectives 

are to: 1) conduct this trial in a mixed rural/urban, high-minority cluster of four counties in a 

previously uninvolved AAA region; 2) recruit 30 primary care physicians and randomize them 

placing 15 in an intervention group and 15 in a usual-care control group; 3) train and support 

intervention group physicians. The expected outcomes include: 1) generating an estimated 

100 new Alzheimer’s disease and related disorder (ADRD) patient/family; and 2) referrals and 

that patients referred by intervention group physicians will receive access to counseling and 

respite services under North Carolina Project CARE, which does not otherwise serve the 

target counties. The outcomes to be evaluated include: 1) rates at which physicians 

diagnose ADRD; 2) rates of referral to ADRD service providers; 3) services provided; 4) 

satisfaction and burden of a sample of family caregivers, 5) hospitalization and nursing home 

placement rates, and 5) estimated costs. Products will include a final report, a cost analysis, 

and articles for nationwide dissemination in academic and popular media, and shared with 

representative of state agencies. 




Project Title: Early Diagnosis Dyadic Intervention-II (EDDI-II) 




50 W. Broad St., 9 th Floor 


Contact: 

Richard LeBlanc 

Tel. No. (614) 644-7967 

Email: dleblanc@age.state.oh.us 



Fiscal 

Year 

Funding 

Amounts 









Total $300,311 

The goal of this project is to evaluate the feasibility, acceptability, and efficacy of the revised 

Early Diagnosis Dyadic Intervention (EDDI-II), a seven-session preventive psychosocial 

“promising practice” found to benefit both the individual with early-stage dementia (IWD) and 

family caregiver (CG). This project is a joint effort of investigators at: Ohio Department of 

Aging; Benjamin Rose Institute; Pennsylvania State University; Alzheimer’s Association 

chapters serving Northern Ohio (i.e., Northwest Ohio, Cleveland, and Greater Ohio chapters); 

and Northeast Ohio Area Agencies on Aging. Project objectives are to: 1) involve 125 IWDs 

and their family CGs in the EDDI-II intervention and evaluate the intervention’s feasibility, 

acceptability, and efficacy; 2) increase the dyad’s current knowledge and understanding 

about dementia and available services; 3) improve communication skills and support between 

the IWD and CG and increase understanding of each other’s care values and preferences; 4) 

improve the IWD’s and CG’s current mental health and quality of life; and 5) disseminate 

project findings and intervention materials. Specific outcomes of the project are: 1) improved 

knowledge, communication, a mutually agreed upon long-term plan of care, and improved 

strategies for maintaining health, self care, well-being, and quality of life for EDDI-II 

participants; and 2) the generation of valuable information about EDDI-II feasibility and 

acceptability. EDDI-II partners will develop and disseminate products including a final report, 

cost analysis, publications in peer-reviewed and professional journals, and EDDI-II treatment 

manual and related project materials. 




Project Title: Evidence-Informed Training Intervention for Hispanic Caregivers of 

persons with ADRD 



Puerto Rico Office of the Ombudsman for the Elderly 

P.O. Box 191179 

San Juan, PR 00912-1179 

Contact: 

Rosanna Lopez-Leon 

Tel. No. (787) 721-6121 

Email: rlopez@ogave.gobierno.pr 


Fiscal 

Year 

Funding 

Amounts 









Total $202,359 


The Puerto Rico Office of the Ombudsman for the Elderly is implementing an Evidenceinformed 

Training Intervention for Hispanic Caregivers of Patients with Alzheimer’s disease 

and related disorders (ADRD). The goal of the project is to implement and evaluate the 

effectiveness of an Evidence-Informed Training Intervention for Hispanic Caregivers of 

Patients with ADRD, which is feasible to replicate and sustain throughout senior centers in 

the Island’s aging service network. The project objectives include to: 1) establish the 

project’s implementation team; 2) establish and sustain the collaborative network and 

coordination among key partners required for project implementation; 3) adapt and implement 

the Evidence-informed Training Intervention; 4) evaluate the processes and outcomes of the 

Evidence-informed Training Intervention; and 5) disseminate the outcomes evaluation and 

lessons learned reports. The expected outcomes include: 1) reduced sense of caregiver 

burden; 2) diminished levels of perceived stress; 3) improved levels of perceived health; 4) 

diminished caregiver health symptoms; and 5) reduced levels of depression. The products 

from this project will include a final report, evaluation reports, a How-to manual, a cost 

analysis, as well as educational materials in Spanish. 




Project Title: Alzheimer's Disease Supportive Services Innovation Program 



South Carolina Office of the Lieutenant Governor 

Office on Aging 

1301 Gervais St. 


Contact: 

Anne Wolf 

Tel. No. (803) 734-9919 

Email: awolf@aging.sc.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $300,000 


The project goal is a re-design intervention to improve access to home and community-based 

services for individuals with Alzheimer’s disease and related dementia by targeting 

underserved minority and rural populations. The South Carolina Lieutenant Governor’s 

Office on Aging will collaborate with the South Carolina Alzheimer's Association, the local 

Aging and Disability Resource Center, the Medical University of South Carolina, and the 

University of South Carolina Objectives are: 1) implement strategies that build familiarity and 

trust among underserved minority populations; 2) provide medical screenings; 3) provide 

vouchers that allow increased services by the community partners, and 4) provide education, 

training and facilitate referral of newly diagnosed persons with Alzheimer's disease to the 

Alzheimer’s Disease Supportive Services Program case manager though primary care 

physicians. Expected outcomes: 1) increased access to services and information; 2) 

increased consumer control; 3) increased trust, familiarity and willingness to use services; 

and 4) effectiveness of intervention to meet outcomes. Products will include: a report on 

lessons learned, an implementation manual, a cost analysis, and semi-annual report data. 




Project Title: Alzheimer and Alzheimer’s and Dementia Related Disorders 

Innovations - Training/Education 




500 Deaderick Street, 8 th Floor, Suite 825 

Nashville, TN 37243-0860 

Contact: 


Tel. No. (615) 741-2056 




Fiscal 

Year 

Funding 

Amounts 









Total $300,000 

Tennessee Commission on Aging and Disability is partnering with Tennessee Alzheimer’s 

Disease Task Force; Alzheimer’s Associations, Eastern Tennessee/Mid-South Chapters; 

East Tennessee and Greater Nashville Area Agencies on Aging and Disability; Council on 

Aging of Greater Nashville; and University of Tennessee, Social Work Office for Research 

and Public Service to apply for the Alzheimer’s Disease Supportive Services: Innovation 

Programs grant. The goal is to enhance Alzheimer’s disease and related dementia (ADRD) 

training/education for primary care and family physicians, emergency room personnel, 

hospital case managers for discharge planning, first responders, and persons with ADRD and 

family members in two Tennessee regions. The objectives are to: 1) gather and identify 

baseline data on current ADRD training/education statewide; 2) design and implement ADRD 

training/education interventions for primary care and family physicians, emergency room 

personnel, hospital case managers for discharge planning, and first responders; 3) provide 

counseling and support services for persons with ADRD, their family members, and 

caregivers; 4) design and implement multiple evaluation strategies to measure outcomes. 

The expected outcomes are to: 1) build a comprehensive database on ADRD 

training/education available on the ADRC website; 2) improve primary care and family 

physicians’ knowledge of ADRD; 3) increase their referrals to community services, and 

improve their relationship with ADRD patients; 4) improve the ability of emergency room 

personnel, case managers for discharge planning, and first responders to interact and 

intervene with persons with ADRD and their family members; 5) increase enrollment in 

community services; and 6) develop a comprehensive, coordinated model for statewide 

training/education. 




Project Title: Community Stress-Busting Program for Family Caregivers of 

Persons with Alzheimer's Disease and Related Dementias 



University of Texas Health Science Center at San Antonio 

7703 Floyd Curl Ave. 

San Antonio, TX 78229-3900 

Contact: 

Dr. Sharon Lewis. 

Tel. No. (210) 949-3696 

Email: lewissl@uthscsa.edu 



Fiscal 

Year 

Funding 

Amounts 









Total $291,153 

The goal of the Community Stress – Busting Program (CSBP) for Family Caregivers is to 

adapt the evidence-informed intervention Stress-Busting Program (SBP) to a lay leader 

model delivered in community settings. The dissemination of this program to large numbers 

of caregivers is a collaborative effort with the grantee, University of Texas Health Science 

Center – San Antonio, WellMed Charitable Foundation, Texas Department of Aging and 

Disability Services, Area Agencies on Aging in Central/South Texas, and South Texas 

Veterans Health Care System. The intervention category is “Evidence-Informed 

Interventions.” The RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, 

and Maintenance) will be used. The objectives include: 1) adapt the SBP to a lay leader 

model; 2) Reach: Determine the extent to which the community-based settings attract the 

intended participants; 3) Effectiveness: Determine the impact on quality of life of caregivers; 

4) Adoption: Assess the factors affecting the adoption of the SBP in the community; 5) 

Implementation: Assess the consistent delivery of the SBP in the community; and 6) 

Maintenance: Determine the requirements needed to maintain delivery of the SBP in the 

community. The expected outcomes include determining: 1) the extent to which community 

agencies attract caregivers to participate; 2) the impact of CSBP on quality of life of 

participating caregivers; 3) the extent to which different settings are involved in the program; 

4) the extent to which the program is delivered consistently and as intended; and 5) extent to 

which the CSBP is sustained, modified, or discontinued over time. The products will be a 

toolkit for stress management for family caregivers, final report including cost analysis, and 

articles for publication. 




Project Title: Creating Care Champions - Provide Caregivers with Access to 

Non-Pharmacologic Treatment And Support Services 




195 N. 1959 W. 


Contact: 

Sonnie Yudall 

Tel. No. (801) 538-3926 




Fiscal 

Year 

Funding 

Amounts 









Total $298,145 

The Utah Division of Aging Services will collaborate with the Alzheimer’s Association Utah 

Chapter (AAUC), the Area Agencies on Aging (AAA) and the VA Hospital and Clinics (VA) to 

improve early and systematic statewide access to non-pharmacologic care of underserved 

dementia caregivers. The goal is to systematically employ an evidence-based homedelivered 

intervention known as Counseling for Caregivers (CFC) at strategic locations 

throughout the State of Utah to address and serve the highest need areas for caregiver 

services. The objectives are to: 1) evaluate the short- and long-term impact of the CFC 

project for reducing neuropsychiatric symptoms and difficult behaviors in the care recipient 

and related distress of the caregiver; 2) assess and document the role of behavioral change 

due to the CFC intervention to significantly reduce caregiver distress and its value and 

applicability in “usual care” post grant; 3) develop and evaluate adjunctive print and webbased 

materials that will support the CFC curriculum among subgroups of caregivers who 

have special resource needs; and 4) evaluate the most effective methods for delivering 

sustainable caregiver group counseling intervention and adjunctive care to caregivers with 

special resource needs. The expected outcomes are: 1) to reduce caregiver distress and 

burden; and 2) to improve quality of life for their dementia care recipients. The products will 

include: a final report, a cost analysis, and publications in peer-reviewed, scholarly journals. 




Project Title: Resources for Enhancing Alzheimer’s Caregiver Health: Offering 

Useful Treatments (REACH OUT) to Rural Dementia Caregivers 



Vermont Department of Disabilities, Aging and Independence 

Division of Aging and Disability Services 

103 South Main St. 

Waterbury, VT 05671-2301 

Contact: 

Maria Mireaut 

Tel. No. (802) 241-3738 

Email: maria.mireault@ahs.state.vt.us 


Fiscal 

Year 

Funding 

Amounts 









Total $300,000 


The State Unit on Aging (SUA) of the Vermont Department of Disabilities, Aging and 

Independent Living (DAIL) partner with home and community based providers in two service 

and planning areas of the state to fulfill the goal of expanding and improving services for 

family caregivers of individuals with Alzheimer’s disease or related disorders (ADRD). The 

project will implement a minor adaptation of the REACH OUT (Resources for Enhancing 

Alzheimer’s Caregiver Health: Offering Useful Treatments) intervention and employ 

technology as a service delivery format. The objectives of the project are to: 1) provide 

caregivers with an evidence-based supportive intervention; 2) train case managers on the 

REACH OUT to Rural Dementia Caregivers intervention; 3) develop linkages between aging 

services network providers and primary care; 4) compare the effectiveness of the face to face 

versus the technology-assisted REACH OUT to Rural Dementia Caregivers intervention; and 

5) evaluate the effectiveness of the project and disseminate the results. The outcomes 

include: 1) improved caregiver self-rated health; 2) increased safety of care recipients; 3) 

broader knowledge of dementia care for case managers; 4) increased access to evidencebased 

dementia caregivers supports; 5) greater collaboration between community partners; 

and 5) caregiver satisfaction with the intervention. The products include semi-annual data 

reports, a final report documenting key elements of the project, a cost-analysis comparing 

REACH OUT to Rural Dementia Caregivers in its regular format versus a technology-assisted 

format, and a manual describing adaptations made to the REACH OUT model and service 

delivery format. 




Project Title: Support for Family Caregivers for Persons with Alzheimer's Disease 

and Related Dementia 




Long Term Care Unit 

1610 Forest Ave. Suite 100 


Contact: 

William Peterson 

Tel. No. (804) 662-9325 

Email: bill.peterson@vda.virginia.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $276,058 


The Virginia Department for Aging, Alzheimer’s Association Central/Western Virginia 

Chapter, University of Virginia, Rappahannock Rapidan Community Services Board/Area 

Agency on Aging, and Aging Together will implement CONNECTIONS, an innovative 

evidence-informed intervention, demonstrate its benefits for individuals with Alzheimer’s’ 

disease and related disorders (ADRD) and family caregivers in rural communities and 

integrate it into Aging and Disability Center (ADRC) Network. The goal is to improve the 

quality of life for persons with ADRD and family caregivers by demonstrating the 

effectiveness of CONNECTIONS as an innovative approach to service delivery and in-home 

intervention. The objectives include: 1) expand number of participants to a minimum of 250 

at-risk individuals/families; 2) focus on a primarily rural, underserved population to address 

geographic isolation challenges, lack of transportation, and service gaps typically pronounced 

in rural areas; 3) enhance the “Home Visitor” model by adding professional staff and 

expanding volunteer corps; 4) strengthen referral base and integrate into ADRC referral 

process; 5) embed into the community and statewide processes and identify sustainable 

funding; 6) expand evaluation tools and data collection; and 7) develop replication products. 

Outcomes include: 1) 90% participants with ADRD will demonstrate increased engagement 

in targeted meaningful activity; positive affect during activity engagement; and 2) 80% 

caregivers will report reduced levels of caregiving burden/stress, increased self-confidence in 

implementing activity programming; additional support from family/friends. Products include: 

a complete activities guide, evaluation tools, implementation manual, report of lessons 

learned, cost analysis and semi-annual data reports 




Project Title: Memory Care and Wellness Services Expansion 



Washington Department of Social and Health Serivces 

Aging and Disability Services 


P.O. Box 45600 

Olympia, WA 98504-5600 

Contact: 

Lynne Korte 

Tel. No. (360)-725-2545 

Email: kortelm@dshs.wa.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $300,000 


Washington State will expand the number of Memory Care and Wellness Services (MCWS) 

sites in collaboration with Area Agencies on Aging, the Alzheimer’s Association, the 

University of Washington and two adult day service providers. The goal of the Memory Care 

and Wellness Services program is to offer people with dementia the support they need to 

stay at home by promoting wellness through exercise, managing health concerns, and by 

decreasing the negative impacts on caregivers. The objectives are to: 1) Expand MCWS to 

a new Area Agency on Aging (AAA) and two new adult day service sites; 2) Serve up to 60 

caregiver/care receiver dyads; 3) Implement MCWS, and the integral EnhanceMobility (EM) 

with fidelity; 4) Demonstrate effectiveness for participants with dementia and their family 

caregivers; 5) Embed MCWS into the Family Caregiver Support Program while engaging 

additional funding sources to support it. The outcomes of this project are that: 1) MCWS use 

will reduce the frequency of behavioral symptoms and improve quality of life for participants 

and 2) will reduce distress related to behaviors, depression, and burden and improve quality 

of life for family caregiver. The products include: data reports, a report of key lessons 

learned, a practical manual for implementing MCWS, and a cost analysis. 




Project Title: Dementia Caregiver Services for Veterans and Families 




Dvision of Long Term Care 


P.O. Box 7580 

Madison, WI 53707-7850 

Contact: 

Ms. Kristen Felton 

Tel. No. (2608) 267-9719 

Email: Kristen.Felten@dhs.wisconsin.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $265,372 


The project goal is to create a dementia capable system with efficient referral processes that 

reduces family caregiver burden and delays nursing home placement for veterans with 

dementia. The Wisconsin Department of Health Services will partner with the Clement J. 

Zablocki Veterans Affairs Medical Center (VAMC), Alzheimer’s Association—Southeastern 

Wisconsin Chapter, Greater Wisconsin Agency on Aging Resources, Inc. and ADRCs in the 

service area. Project objectives are: 1) re-design the interagency referral process between 

the VAMC, Aging and disability Resource Centers (ADRCs) and the Chapter in a select area; 

2) assess staff knowledge and develop educational programs about dementia, caregiver 

needs, partner expertise and the referral processes; 3) provide education, support, 

consultation and respite services to family caregivers at the VAMC, Union Grove Clinic and 

select non-VA sites, and 4) disseminate project findings. The project outcomes are: 1) 

caregivers of veterans with dementia will receive referrals for services to and from the VAMC, 

Chapter and ADRCs; 2) professionals at partner organizations are dementia capable and 

refer family caregivers for services and supports to the organization that can best meet 

identified needs; 3) reduction in caregiver burden will delay nursing home placement for 

veterans with dementia, and 4) project findings will be available locally and nationally. 

Products for this project are a final report with project findings, ADRC video and brochure, an 

implementation manual, cost analysis and semi-annual data reports. 


Chronic Disease Self-Management Program 

The American Recovery and Reinvestment Act of 2009 (AARA) was designed to stimulate 

economic recovery in various ways including reduction of healthcare costs through 

prevention activities. The Administration on Aging (AoA) received a portion of the $650 

million appropriated for the Communities Putting Prevention to Work initiative managed by 

the Centers for Disease Control for the AoA Chronic Disease Self Management Program 

(CDSMP). Two CDSMP grant competitions were held in FY2010, one to support a National 

Center to provide technical assistance and evaluation support for AoA and a second to 

support CDSMP grants in forty-five States, the District of Columbia and Puerto Rico to deploy 

evidence-based chronic disease self-management programs targeted at older adults with 

chronic conditions. 

Since 2003, AoA in collaboration with the Centers for Disease Control and Prevention (CDC), 

the Agency for Healthcare Research and Quality (AHRQ), the Centers for Medicare and 

Medicaid Services (CMS) and other Department of Health and Human Services (HHS) and 

private sector partners, has funded collaborations between the aging and public health 

networks at the State and community level to deploy evidence-based prevention programs, 

including chronic-disease self-management programs, targeted at older adults. This AoA led 

effort resulted in the delivery of chronic disease self-management programs in over 1,200 

community-based sites across 24 states that have served over 12,000 seniors. 

. 

Additional information about the CDSMP and funding from the American Recovery and 

Reinvestment Act Putting Communities to Work Initiative may be viewed on the AoA website: 

http://www.aoa.gov/AoARoot/AoA Programs/HPW/ARRA/index.aspx 


Chronic Disease Self-Management Program State Grants 

In FY2010 the Administration on Aging held a competition open to State government State 

units on aging or health departments. Either could apply as the lead agency but both must 

collaborate to be competitive for receiving a cooperative agreement with AoA to develop and 

sustain a distribution and delivery system to be used to systematically deliver Chronic 

Disease Self Management Programs (CDSMP and other evidence-based prevention 

programs for older adults statewide. Applicants were also asked to develop quality 

assurance programs, partner with other public and private sector organizations, and identify 

and select local communities to administer CDSMP programs. States were encouraged to 

select geographic areas that facilitate the targeting of older adults, including low-income, 

minority, and limited English speaking older adults with chronic diseases. 

A total of 47 awards were made to 46 States and the District of Columbia for $27 million in 

FY2010. 

Additional information about the CDSMP and funding from the American Recovery and 

Reinvestment Act Putting Communities to Work Initiative may be viewed on the AoA website: 

http://www.aoa.gov/AoARoot/AoA Programs/HPW/ARRA/index.aspx 


Program: Chronic Disease Self-Management Program State Grants 

Grant Number: 90RA0002 

Project Title: Alabama's American Recovery and Reinvestment Act Chronic 

Disease Self-Management Program 

Project Period: 03/31/2010 - 03/30/2012 




770 Washington Avenue, Suite 570 

P.O. Box 301851 


Contact: 

Julie Miller 

Tel. (334) 242-5743 

Email: Julie.Miller@ADSS.Alabama.gov 


Fiscal Funding 

Year Amount 


Total $600,000 


Alabama Department of Senior Services, Department of Public Health, Medicaid Agency, 

Northwest Alabama Council of Local Governments, and Regional Council of Governments 

are working together to increase the quality of life for older Alabamians by teaching them selfmanagement 

skills for living a healthy lifestyle. The state will: 1) implement the Stanford 

Chronic Disease Self-Management Program (CDSMP) in two geographic areas covering ten 

counties; 2) embed its existing wellness and disease prevention component "Living Well 

Alabama" which utilizes the Stanford CDSMP in its short and long term health prevention 

initiatives for Area Agencies on Aging (AAAs); 3) train a minimum of 800 individuals; and 4) 

provide master and leader training to all areas of the state to sustain the program. The target 

population for this project is older adults age 60+ diagnosed with chronic diseases. The state 

will focus on those that are low income and/or minorities. Outcomes include: 1) older adults 

in the state having reduced risk factors for chronic disease and long-term disabilities; 2) 

educated caregivers; 3) collected data; and 4) support for self-efficacy of individual healthy 

behaviors. 




Project Title: Alaska American Recovery and Reinvestment Act Chronic Disease 

Self-Management Program 



Alaska Deptment of Health and Social Services 

350 Main Street, Rm. 427 

Juneau, AK 99811 


Year Amount 


Contact: 

Barbara Stillwater 

Tel. (907) 269-8035 

Email: barbara.stillwater@alaska.gov 



Total $50,000 

This project will expand the Chronic Disease Self-Management Program (CDSMP) in Alaska 

to address the needs of its aging population, especially the increase in chronic disease 

prevalence, risk factors, and co-morbidities, and the lack of health education programs 

appropriate for seniors with chronic conditions. The Alaska Department of Health and Social 

Services is the State’s federally designated Unit on Aging whose responsibilities are jointly 

executed by the Division of Senior and Disabilities Services and the Alaska Commission on 

Aging. Alaska is considered a single planning and service area (PSA) without AAAs because 

until recently, it did not have a sufficiently large senior population to warrant regional 

infrastructure development. This creates a challenge to the 60 independent operating senior 

centers in Alaska which are often far from the State capital in Juneau. The project goal is to 

integrate CDSMP into the social and health systems serving seniors in Alaska. Objectives 

include: 1) developing an infrastructure to house CDSMP in 16 senior centers; 2) through the 

training and mentoring of 100 senior course leaders, through technical assistance to staff at 

16 senior centers; 3) through providing workshops to 450 seniors, and 4) through a 

participant referral network involving Medicaid, the Aging and Disability Resource Centers 

(ADRCs), the Real Choice Systems Change Hospital Discharge Planners, community health 

centers, and primary healthcare providers. Anticipated outcomes include: 1) an increase in 

the number of CDSMP courses taught at senior centers; 2) an increase workshop 

participants; 3) a sustainable CDSMP delivery system in Alaska; and 4) a continuous quality 

improvement system to ensure CDSMP fidelity. The products of this project are a technical 

assistance listserv, a fidelity action plan, promotional and referral materials for CDSMP, and 

process and outcome data. 


Program: Chronic Disease Self-Management Program – State Grants 


Project Title: American Recovery and Reimbursement Act Arizona Living Well 

Grant 



Arizona Department of Health Services 

1740 W Adams St. 

Phoenix, Arizona 85007 

Contact 

Ramona Rusinak 

Tel. No. (602) 364-0526 

Email: rusinar@azdhs.gov 



Fiscal 

Year 

Funding 

Amounts 









Total $600,000 

The Arizona Living Well Expansion Project’s goal is to increase the availability of selfmanagement 

and health promotion programs in Arizona, helping to maintain independence, 

health, and quality of life among those 60 years and older. Arizona presents a host of 

challenges and opportunities for revamping its infrastructure related to aging. One quarter of 

its population will be age 60 and older, 85 percent of those 65 and older report at least one 

chronic disease, and a disproportionate chronic disease burden is seen in minority 

populations. The objectives of this project are to: 1) implement the business plan to develop 

the Arizona Living Well Initiative, 2) expand public and professional awareness and 

knowledge of benefits and importance of providing CDSMP courses and leverage 

partnerships, and 3) develop key partnerships to target program delivery to populations with 

health disparities and inequities The outcomes of this project include: 1) an increase in selfreports 

of general health, 2) health care utilization, physical activity, communication with 

healthcare providers, 3) confidence about doing things, and 4) a decrease in limitations for 

physical activity, pain and fatigue, and health interference with daily activities. The products 

from this project are budgetary and programmatic reports, project timelines, checklist for 

leader observation, and participant feedback forms. 




Project Title: Arkansas American Recovery and Reimbursement Act Chronic 

Disease Self-Management Project 



Arkansas Department of Health 

4815 W. Markham Slot #41 

Little Rock, AR 72205 

Contact 

Dianna Hall-Clutts 

Tel. No. (501) 2804743 

Email: diannia.hall-clutts@arkansas.gov 



Fiscal 

Year 

Funding 

Amounts 









Total $400,000 

The Arkansas Department of Health (ADH), in a collaborative effort with the Arkansas 

Department of Human Services/Division of Aging and Adult Services (DHS/DAAS), is 

conducting a two-year project to expand the existing capacity to deliver the Stanford Chronic 

Disease Self-Management Program (CDSMP) statewide. The ADH and DHS/DAAS have as 

partners the Arkansas Area Agencies on Aging (AAA), the University of Arkansas for Medical 

Sciences (UAMS) Reynolds Institute on Aging/Arkansas Aging Initiative Center on Aging 

(AAI/COA), Arkansas Senior Centers Association (ASCA), Community Hometown Health 

Improvement coalition (HHI), Aging and Disability Resource Centers (ADRC), and the 

Arkansas Department of Human Services/Division of Medicaid Services. The goal is to 

expand the existing capacity within the state to deliver the CDSMP through an expanded 

infrastructure and distribution system within the statewide aging network community. The 

objective is to increase the ability of community-based collaborative networks to deliver the 

CDSMP to 500 participants statewide. The proposed infrastructure includes a quality 

assurance component to ensure that programs are delivered with fidelity and achieve optimal 

results as designed in the original model. The major outcome of this project is that the 

infrastructure and statewide distribution system will be in place and strengthened by a 

statewide referral resource system. Indicators will be: 1) an increased number of active lay 

leaders in the state; 2) an increased number of CDSMP course participants that meet or 

exceed the minimum number required for the grant (500); 3) the commitment of participants 

to a positive lifestyle change which will improve their quality of life; and 4) community-based 

networks working in unison to bring about the sustainability of the program within the state. 

Expected products include: progress reports and quarterly ARRA reporting. 




Project Title: California's American Recovery and Reinvestment Act Chronic 

Disease Self Management Program Initiative 



California Department of Aging 

1300 National Drive, Suite 200 

Sacramento, CA 95834 

Contact 

Janet Tedesco 

Tel. No. (916) 928-4641 

Email: jtedesco@aging.ca.gov 



Fiscal 

Year 

Funding 

Amounts 

FY2010 $1,000,000 








Total $1,000,000 

The California Department of Aging, is partnering with the state Departments of Public Health 

and Health Care Services to expand the availability of the Chronic Disease Self-Management 

Program (CDSMP). Through the State’s leadership, local Area Agencies on Aging and 

health departments will coordinate program delivery with their designated lead community 

organizations. California’s goal is to make the CDSMP available to at least 2,975 older adults 

during the next 24 months. The target population includes older adults who are low income, 

ethnically diverse, limited/non English speaking, Medi-Cal eligible, and/or older veterans. 

The objectives are to: 1) implement the CDSMP in 11 counties that are home to over 40% 

(2.6 million) of the state’s older adult population; 2) provide technical assistance to these 

counties, as well as organizations in other areas of the state that conduct the CDSMP or the 

Diabetes or Arthritis Self Management Programs, in their implementation efforts; 3) monitor 

and evaluate the process and outcomes to ensure fidelity to the program model; 4) share 

resources, lessons learned and promising practices among the counties; and 5) disseminate 

findings to influence statewide program adoption. The expected outcomes are: 1) 

implement/expand the CDSMP’s availability in some rural areas of the state while achieving 

deeper program penetration in more densely populated counties; 2) enhance the statewide 

infrastructures to adequately support program expansion into more geographic areas, while 

maintaining program fidelity to the original research and; 3) conduct outreach and enrollment 

activities to ensure that 4,500 older adults complete the CDSMP. The products are progress 

reports, quarterly ARRA reporting, website enhancements to a centralized workshop 

schedule database, publications, consumer outreach materials, and conference 

presentations. 




Project Title: Colorado American Recovery and Reinvestment Act Chronic 

Disease Self-Management 



Colorado Department of Public Health and Environment 

Center for Healthy Living 

4300 Cherry Creek Drive South 


Contact: 

Karen Deleeuw 

Tel. (303) 692-2515 

Email: karen.deleeuw@state.co.us 



Year Amount 


Total $452,582 


Since 2006, the Colorado Department of Public Health and Environment (CDPHE), the 

Colorado State Unit on Aging (SUA), and the Consortium for Older Adult Wellness (COAW) 

have worked in partnership to build infrastructure for community implementation of programs 

from the Stanford Chronic Disease Self-Management Program (CDSMP) series in Colorado. 

COAW, a private, non-profit organization, coordinates a statewide system of training, 

implementation, fidelity assurance and technical assistance. CDPHE and SUA build 

partnerships and develop resources to enhance the system and expand implementation. 

Through this grant, the partnership will extend the reach of the CDSMP series to an 

additional 700 Coloradans over two years. Four local lead agencies will participate to build 

sustainable capacity for class implementation through community-based organizations. 

These agencies include Area Agencies on Aging serving Weld County, the six-county San 

Luis Valley region, and the eight-county Denver Metro area, and the local health department 

in Larimer County. These regions cover 67 percent of the State’s population, and reach lowincome 

and racial and ethnic minority populations. CDPHE ensures compliance with AoA 

and Recovery Act reporting requirements, monitors grant activities, executes and monitors 

contracts, provides technical assistance to the state partnership and local lead agencies, 

coordinate the established CDSMP data system and leads an effort to establish health plan 

reimbursement. SUA oversees grant implementation, provides technical assistance to the 

state partnership and local lead agencies, and builds referrals to CDSMP classes through 

Colorado’s Aging and Disability Resource Centers. The Colorado Department of Health Care 

Planning and Financing promotes CDSMP classes to the Medicaid population. 




Project Title: Connecticut Live Well/Chronic Disease Self-Management Statewide 

Project 







Year Amount 


Contact: 

Pamela Giannini 

Tel. (860) 424-5277 

Email: pamela.giannini@ct.gov 



Total $400,000 

The Connecticut Department of Social Services/Aging Services Division will partner with the 

Department of Public Health to expand the existing Stanford Chronic Disease Self- 

Management Program (CDSMP) from the current geographic offerings into the Eastern, 

Western and Southwestern areas of the state. Our goal is to work with the Connecticut Area 

Agencies on Aging and link with community based organizations in these regions to empower 

older people to take more control over their health through lifestyle changes and chronic 

disease management. This project is part of the systems change to targeting the State’s 

most vulnerable older adults including partnership with the State Medicaid Program and 

Medicaid Access Agencies as partners in a referral system as part of Connecticut’s home 

and community based waiver program - CT Home Care Program for Elders (CT). Using our 

experiences and lessons learned from the current 2007 Administration on Aging Evidence- 

Based Program Grant, this project will address health disparities and build an infrastructure to 

support a sustainable program in the English and Spanish/ Tomando versions of the Chronic 

Disease Self-Management Program. Working with regional and community partners, and 

leveraging other public and private resources, the Social Services/Aging Services Division 

will provide 15 English language leader trainings and 3 Spanish/Tomando trainings to reach 

500 seniors living with a chronic disease. The CT program will collect data on participant 

demographics and satisfaction as well as monitor fidelity and quality assurance and will 

convene an advisory board to review grant progress. The expected products include print 

and web-based procedure manuals and materials, consumer evaluation results, and a cadre 

of trained professional and lay persons. 




Project Title: Delaware American Recovery and Reinvestment Act Chronic 




Delaware Department of Health and Social Services 

Dvision of Public Health 

417 Federal St. 

Dover, DE 19901 

Contact 

Don Post 

Tel. No. (302) 744-1020 

Email: donald.post@state.de.us 


Fiscal 

Year 

Funding 

Amounts 









Total $100,000 


The goal of Delaware’s two year project is to establish Stanford’s Diabetes Self-Management 

Program (DSMP) in Delaware and to ultimately incorporate other evidence based programs, 

including the Chronic Disease Self-Management Program (CDSMP) and the Spanish version 

of the DSMP Tomando Control de su Diabetes. This grant will also provide the foundation to 

model and develop self-management programs addressing other specific chronic diseases. 

The objectives of this proposal include: 1) train 14 lay persons to receive their certificates as 

Lay Leaders; 2) train six of the Lay Leaders to become Master Trainers; 3) establish ten sites 

to conduct DSMP; 4) conduct ten DSMP six-week series workshops by year two; 5) have 139 

older adult participants receive a certificate of completion for completing the diabetes module 

classes; and 6) obtain a license for the Delaware’s Division of Public Health for at least one 

Stanford Self-Management Program model. The outcomes of this proposal include: 1) an 

increased knowledge in the target population regarding the importance of disease 

management and control; 2) an increase in their utilization of standard diabetes exams; 3) 

one-on-one consultations with high risk individuals regarding participation in DSMP; 4) 

reduced non-compliance with physician recommended diabetes self-management measures; 

and 5) reduced health disparities among high-risk populations. The products of this proposal 

include measures of Lay Leader and Master Trainer certification; measures of the number of 

DSMP workshops conducted and the number of participants; surveys of both presenter and 

content satisfaction; and a sustainability plan developed in conjunction with Delaware’s 

Division of Public Health, Division of Aging and Older Adults with Physical Disabilities, and 

Medicaid. 




Project Title: District of Columbia American Recovery and Reinvestment Act 





441 4th Street NW #900 South 



Year Amount 


Contact: 


Tel. (202) 724-4382 




Total $50,000 

The District of Columbia Office on Aging and the Aging and Disability Resource Center in 

collaboration with the Department of Health, Department of Health Care Finance, and 

community-based partners, will implement the Stanford University Diabetes Self- 

Management Program (DSMP) for older diabetics in the community. This project will learn 

how best to improve the self-care skills of District Medicare seniors with Type 2 diabetes by 

providing the DSMP to at least 104 participants at four of its senior Wellness Centers in four 

of the neediest Wards (4, 5, 7, and 8). The project objectives are: 1) to enhance participants' 

quality of life; 2) to reduce unnecessary hospitalizations and emergency visits; 3) to 

strengthen the District's capacity and commitment to implement, deliver, and sustain chronic 

disease self-management programs for all affected residents; 4) and to assure that the 

DSMP is delivered with fidelity and thereby to learn how results compare to those produced 

in Stanford's original research. 




Project Title: Florida American Recovery and Reinvestment Act Chronic Disease 

Self-Management Program Project 




4040 Esplanade Way 



Year Amount 


Contact: 

Michele Mule 

Tel. (850) 414-2000 

Email: Mulem@elderaffairs.org 



Total $1,000,000 

The Florida Department on Elder Affairs (FDOEA) will build a statewide program 

infrastructure for administration of a Chronic Disease Self-Management Program (CDSMP). 

The project goals are to enhance existing evidence-based programs, expand CDSMP efforts 

into new areas of the state, and target hard-to-serve populations such as limited-English 

speakers, low-income individuals, minorities, Medicaid eligible individuals and rural residents. 

These goals will be achieved through the following objectives: 1) include CDSMP under a 

Medicaid waiver; 2) recruit the efforts of the FDOEA Long-Term Care Community Diversion 

Pilot Project providers; 3) make CDSMP information available in Aging and Disability 

Resource Centers; 4) leverage FDOH grant funding to purchase three to four licenses for 

project lead agencies; and 5) increase the number of volunteer leaders in project Planning 

and Service Areas. The expected outcomes of the proposed project include: 1) increased 

self-efficacy in managing chronic conditions among adults age 60 and older; 2) increased 

availability of health services to minority, low-income, and rural individuals; and 3) a more 

efficient referral system for individuals to CDSMP. The products of the proposed project 

include monthly narrative reports submitted to FDOEA, excel spreadsheets and invoices to 

ensure compliance with the contract and program requirements, participant data for project 

evaluation, and a CDSMP lending library of Stanford course material. 


Program: Program: Chronic Disease Self-Management Program State Grants 


Project Title: Chronic Disease Self-Management Program (CDSMP). 





Two Peachtree Street, NW, Suite 9-398 


Contact 

Jamie Cramer 

Tel. No. (404) 429-5322 

Email: jacramer@dhr.state.ga.us 


Fiscal 

Year 

Funding 

Amounts 









Total $905,164 


The Georgia Department of Human Services (DHS) Division of Aging Services (DAS) and the 

Department of Community Health (includes Division of Public Health and the Medicaid 

Agency) will work with their regional and local partners to provide Chronic Disease Self- 

Management (CDSMP) and other Evidence-Based Prevention Programs (EBPP) to increase 

the quality of life for seniors with chronic diseases. Objectives: 1) create a plan to implement 

CDSMP in five geographic regions to reach 1358 older adults who complete the workshops; 

2) train lead agency leaders to conduct CDSMP programs; 3) conduct 135 workshops in five 

regions, targeting older adults, especially underserved groups; 4) develop a quality 

assurance plan to ensure fidelity for EBPP; and 5) evaluate these programs for changes in 

behavior, health status, and health care utilization. The project will also develop and sustain 

an infrastructure of partnerships for integrating CDSMP and other evidence-based programs 

into public health and long-term care systems. Objectives: 1) develop a business plan for 

deploying and sustaining CDSMP programs; 2) re-establish Georgia Coalition for Healthy 

Aging (GCHA) to assist in strategic planning around the implementation of CDSMP and 

advocate for EBPP; 3) expand and support the role of AAAs in implementing EBPP; 4) 

provide leadership, consultation and on-going support to local partners. Participant outcomes 

are that the program participants: 1) will show increased self-confidence; 2) improved health 

status, and 3) increased self-management behaviors. System Outcomes will be: 1) an 

increase in the number of CDSMP programs in the state; and 2) reductions in health care 

utilization and costs. Products include health promotion materials; reports on project results 

reporting participant and system outcomes and demographics of program participants. 




Project Title: Hawaii's Healthy Aging Partnership Chronic Disease Self- 

Management Program 



Hawaii Executive Office On Aging 

Department Of Health 

No.1 Capitol District 250 S. Hotel Street, Suite 406 

Honolulu, Hi 96813 

Contact: 

Nancy Moser 

Tel. (808) 586-0100 

Email: nancy.moser@doh.hawaii.gov 



Year Amount 


Total $200,000 


The Hawaii Executive Office on Aging (EOA) will continue to conduct the Chronic Disease 

Self-Management Program (CDSMP) in collaboration with the state Department of Health, 

Area Agencies on Aging, and community service providers. The goal is to empower older 

adults with chronic disease to maintain and improve their health using the Stanford University 

CDSMP, Arthritis Self-Management and Diabetes Self Management Programs and to make 

evidence-based health promotion readily available to all. The objectives are to: 1) extend 

the program’s reach to additional communities that include older adults with low income, 

minorities and limited English speakers with chronic diseases; 2) establish referral linkages 

between Hawaii’s Aging and Disability Resource Center (ADRC) and health clinics, physician 

practices, hospital discharge planners, and other community services providers; 3) recruit 

and train local community members to certify as Lay Leaders and deliver workshops with 

fidelity in their own communities; 4) provide CDSMP workshops to older adults; and 5) 

measure changes in participants’ health status after they learn and use CDSMP skills. 

Expected outcomes are: 1) Hawaii’s Aging Partnership (HAP) will expand to offer CDSMP 

workshops in 13 new communities; 2) referral linkages will be established with community 

health care providers ; 3) local Lay Leaders will be trained; 4) at least 532 older adults with 

chronic diseases will complete at least 4 out of 6 sessions in a CDSMP cycle; and 5) 

completers will demonstrate increases in self-rated health status, confidence in using selfmanagement 

skills, and decreases in self-reported use of physician, hospital, and emergency 

room services. 




Project Title: Living Well in Idaho American Recovery and Reinvestment Act 

Program Expansion 



Idaho Department of Health and Welfare 

450 W. State Street - 6th Floor 



Year Amount 


Contact: 

Elke Shaw-Tulloch 

Tel. (208) 334-5927 

Email: shawe@dhw.idaho.gov 



Total $200,000 

The Idaho Department of Health and Welfare (IDHW), in partnership with the Idaho 

Commission on Aging (ICOA), will expand Living Well in Idaho, Stanford University’s Chronic 

Disease Self-Management Program (CDSMP), and introduce the Spanish CDSMP into two of 

Idaho’s seven public health districts, Southwest District Health (Health District 3) and Central 

District Health (Health District 4). The project goal is to expand the CDSMP and implement 

Spanish CDSMP in two local public health districts, which include rural and resource-poor 

areas serving low-income, minority and limited English speaking older adults. It will build on 

an existing fall prevention program delivery infrastructure to create a sustainable program. 

The objectives are to: 1) contract with Health Districts 3 and 4 to lead local efforts to expand 

and implement the CDSMP and Spanish CDSMP; 2) guide Health Districts 3 and 4 to 

contract with three community-based human services organizations for a total of six 

organizations implementing CDSMP and Spanish CDSMP to their site and in other sites in 

their communities; 3) create a cadre of trained Master Trainers and lay leaders in service to 

each community-based human services organization; 4) ensure that each of the six 

community-based human services organizations conducts at least seven CDSMP workshops; 

5) increase the capacity to serve at least 500 new CDSMP participants through the expanded 

workshops; 6) develop working partnerships with the Division of Medicaid, Southwest Idaho 

Area Agency on Aging (AAA), Aging and Disability Resource Connections (ADRC) to refer 

older adults to the Living Well in Idaho program; and 7) develop the capacity to sustain the 

program. Boise State University’s Center for the Study of Aging will continue to serve as the 

external evaluation partner responsible for assuring that the programs are implemented with 

fidelity to the evidence-based models. 




Project Title: Illinois Chronic Disease Self Management Project 



Illinois Department of Public Health 

Office of Health Promotion 

535 West Jefferson St. 


Contact 

Thomas J. Schafer 

Tel. No. (217) 782-3300 

Email: tom.schafer@illinois.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $1,000,000 


The Illinois Department of Public Health, in partnership with the Illinois Department on Aging 

(IDoA), will work together to achieve the following goal: expand the Chronic Disease Self- 

Management Program (CDSMP) and the Diabetes Self-Management Program (DSMP) in 

English and Spanish for persons over age 60. This will be accomplished through communitylevel 

aging and public health service provider organizations, reaching at least 2,975 

completers (of an estimated 5,143 participants). The objectives are: 1) to expand CDSMP 

and DSMP in three existing Planning and Service Areas (PSA) as defined by the Older 

Americans Act, and to begin implementation of CDSMP and DSMP in 10 additional Planning 

and Service Areas; 2) to strengthen and broaden the infrastructure and partnerships 

necessary to effectively embed and sustain these programs within statewide systems; 3) to 

evaluate the efforts of each evidence-based intervention to assure program fidelity and 

quality; and 4) to share subsequent results and findings. The outcomes of the proposed 

project include: 1) improvements in exercise, cognitive symptom management, 

communication with physicians, self-reported general health; and 2) reduced health distress, 

fatigue, disability, and social/role activities limitations. The products of the proposed project 

include sustainability plans created by Area Agencies on Aging for their Planning and Service 

area, analyses of participant data and fidelity findings, records of Master Trainer and Lay 

Leader activity, and reports delivered by Planning and Service Area fidelity monitors. 




Project Title: Indiana American Recovery and Reinvestment Act Living a Healthy 

Life Partnership 




402 W. Washington Street E442 

Indianapolis, IN 46204 


Year Amount 


Contact: 


Tel. (317) 234-1749 




Total $600,000 

The Living a Healthy Life Partnership (Healthy Life Partnership) which includes the Indiana 

Division of Aging (DA), the Indiana State Department of Health (ISDH), the Indiana Office of 

Medicaid Policy and Planning (OMPP), local Area Agencies on Aging, local health 

departments (LHD), Indiana Minority Health Coalition (IMHC) and its local coalitions, 

physician groups, hospitals and other various community groups will with this grant ensure 

that the Stanford University Chronic Disease Self Management Program (CDSMP), currently 

provided by many of Indiana’s Area Agencies on Aging (AAAs), will reach a broader 

population of older adults, including low-income, minority, and limited-English-speaking 

seniors. The partners will incorporate the existing CDSMP resources into a larger and 

stronger network to create a system for delivery of CDSMP statewide for older adults in 

Indiana resulting in a strong foundation built within local communities and supported by 

statewide agencies and resources that will sustain it beyond the end of this grant. Indiana 

will focus on the following objectives: 1) expand capacity to deliver evidence-based 

programs through the development of a statewide infrastructure, 2) develop a comprehensive 

method of quality assurance and fidelity, 3) promote evidence-based programs to older adults 

using the AAAs/Aging and Disability Resource Centers (ADRCs) as the catalyst for 

developing local level partnerships, and 4) target minority populations through non-traditional 

aging resources. Indiana will have each AAA/ADRC hire or designate a Health and Wellness 

Coordinator whose duties include but are not limited to training lay leaders, teaching 

workshops, performing fidelity reports, creating partnerships with other organizations, and 

compiling reports. 




Project Title: Kansas Chronic Disease Self-Management Program 




503 S Kansas Ave. 

Topeka, KS 66603 

Contact 

Joyce Smith 

Tel. No. (785) 291-3356 

Email: Joyce.Smith@aging.ks.gov 



Fiscal 

Year 

Funding 

Amounts 









Total $400,000 

The Kansas Department on Aging (KDOA) is working in collaboration with the KS Dept. of 

Health and Environment, Division of Health, to develop the Stanford University Chronic 

Disease Self-Management Program (CDSMP) and Spanish CDSMP Tomando Control de su 

Salud (Tomando) within the state’s aging and public health networks. The goals of this 

proposed project are to build infrastructure for expanding state capacity to deliver the 

programs; to develop a management system at KDOA to implement and maintain the 

programs; and to develop a system to measure CDSMP and Tomando outcomes. The 

project objectives are: 1) to build capacity to administer the programs at the KDOA; 2) to 

develop CDSMP and Tomando sustainability plans; 3) to build capacity to implement the 

programs locally; 4) to ensure fidelity; and 5) to reach at least 500 adults age 60 and older. 

The expected outcomes include: 1) improvements in exercise cognitive symptom 

management, communication with physicians, self-reported general health; and reductions in 

health distress, fatigue, disability, and social/role activities limitations. The products of this 

project include marketing materials to be supplied to Lay Leaders, participant and leader 

training evaluation forms, and a sustainability plan developed through policy initiatives. 




Project Title: Kentucky's American Recovery and Reinvestment Act Chronic 

Disease Self Management Program 



Kentucky Cabinet for Health and Family Services 

Aging and Independent Living 

275 East Main Street, 3E-E 

Frankfort , KY 40621 

Contact: 

Carla Crane 

Tel. (502) 564-6930 

Email: carla.crane@ky.gov 



Year Amount 


Total $600,000 


Kentucky will strengthen both state and community-level partnerships between the 

Department for Aging and Independent Living (DAIL), Department for Medicaid Services 

(DMS), and Department for Public Health (DPH) to employ the systematic offering of the 

Chronic Disease Self-Management Program (CDSMP) across the State. At the state level, 

Departments will collaborate and uniformly communicate project goals with parallel 

community agencies. At the community level, the employment of CDSMP will be initiated 

within five of the fifteen (15) regional Area Agencies on Aging and Independent Living 

(AAAIL). Participating AAAIL regions include the most densely populated areas within the 

state: Bluegrass (Lexington) and KIPDA (Louisville), in addition to, Northern Kentucky 

(adjacent to Cincinnati, Ohio), Green River (Owensboro) and FIVCO (Ashland). Each AAAIL 

will strengthen their community relationships, including key partnerships, as demonstrated 

within their corresponding sub-work plans. In the first year activities will be concentrated in 

the participating five regions of the state but by the end of the grant all fifteen AAAILs will 

have a minimum of two master level trainers to facilitate statewide implementation of 

CDSMP. It is anticipated that 1,000 participants will complete the CDSMP course. Project 

objectives are: 1) strengthen collaboration between DAIL, DMS and DPH; 2) seek T-Trainer 

authorization for a minimum of four individuals; 3) market program statewide; 4) coordinate 

data collection and reporting; and, 5) evaluate implementation, fidelity, and certification 

authorization. 




Project Title: Stanford Chronic Disease Self-Management Program in Louisiana 



Louisiana Governor’s Office of Elderly Affairs 

525 Florida Blvd. 

Baton Rouge, LA 70801 

Contact 

Matt W. Estade 

Tel. No. (225) 342-3570 

Email: mwestrade@goea.la.gov 



Fiscal 

Year 

Funding 

Amounts 









Total $400,000 

The Louisiana Governor’s Office of Elderly Affairs (GOEA), in partnership with several state 

agencies is proposing to implement the Stanford Chronic Disease Self-Management Program 

(CDSMP). Major partner agencies include the Department of Health and Hospitals’ Chronic 

Disease Prevention and Control Unit (CDPCU) which is in the Bureau of Primary and Rural 

Health, Office of Aging and Adult Services (OAAS). Other partners include the University of 

Louisiana Monroe (ULM), Louisiana State University Health Sciences Center (LSUHSC), the 

State Medicaid agency, and AARP. The goal of the project is to provide the CDSMP to older 

adults over age 60 through the Louisiana Aging Network. The objectives of the project are to: 

1) deliver the Stanford curriculum to 500 older adults who complete the program; 2) create 

infrastructure and partnerships necessary to embed this health education program for older 

adults within statewide delivery systems for health and long term care; and 3) evaluate 

program effectiveness at the participant level, partner level, and state level. The expected 

outcomes of the project are: 1) the potential for improving the quality of life for seniors; 2) 

improved health status; 3) change in behavioral risk factors; 4) reduction of the use and cost 

of health care over time; and 5) at the state level, integration of CDSMP into the larger scope 

of existing prevention programs to creation of a sustainable infrastructure for its delivery. The 

four products from this project are a final report, including client-tracking and program 

evaluation; results of monitoring program fidelity; publications and presentations at 

conferences; educational opportunities for health care providers and aging professionals in 

academic settings; and an infrastructure for communication between program developers and 

practitioners in public health and aging. 




Project Title: Maine Statewide American Recovery and Reinvestment Act Chronic 

Disease Self-Management Program Dissemination 



Maine Department of Human Services 


11 State House Station 32 Blossom Drive 

Augusta, ME 04333-0011 

Contact: 

Kathleen M. Poulin 

Tel. (207) 287-9206 

Email: kathy.poulin@maine.gov 



Year Amount 


Total $200,000 


Maine’s Office of Elder Services and Maine’s Center for Disease Control and Prevention are 

collaborating with MaineHealth, District Health Offices, area agencies on aging, Division of 

Employee Health and Benefits, Medicaid Office and community based human services 

organizations to expand access and enhance sustainability of the Chronic Disease Self- 

Management Program (CDSMP) for older adults. This grant will expand Maine’s capacity to 

deliver CDSMP statewide, maintain fidelity to the model, strengthen the physician practice 

based model, and develop an employer based model with State employees and retirees. 

Objectives are: 1) to increase access for 400 older adults; 2) to increase the number of 

volunteer leaders and master trainers; 3) to increase participation of state employees and 

consumers in practice based models; 4) to maintain fidelity, evaluate and monitor impact on 

health, and 5) strengthen collaboration between AAAs and public health and sustainability of 

the program. Emphasis will be on new and strengthened partnerships with primary care and 

patient centered medical home pilot sites and the state employee/retiree health program. 

Quality assurance and fidelity are achieved though Stanford University’s model of master 

trainers training and supervising lay leaders, regular quality assurance program site visits, a 

completed fidelity checklist for each CDSMP class, and program fidelity data collected as part 

of the program evaluation. MaineHealth’s Center for Quality and Safety will conduct the data 

analysis and provide semi-annual outcome reports. 




Project Title: Maryland American Recovery and Reinvestment Act Chronic 





301 West Preston St. 15th Floor 



Year Amount 


Contact: 

Donna Smith 

Tel. (443) 473-9228 

Email: dms@ooa.state.md.us 



Total $600,000 

Health Promotion is a vital component of the Maryland Department of Aging’s (MDOA) vision 

of assisting older Marylanders to age in place with dignity, opportunity, choice and 

independence. Enhancing the quality of health education and physical fitness is a primary 

goal of MDOA. As the population ages and medical expenses grow more costly, it is 

important for state and local officials to implement evidence-based (EB) prevention programs 

such as Chronic Disease Self Management Program (CDMSP) to help reduce the cost of 

chronic conditions and help patients improve the quality of their lives. Using this new 

approach, this project will expand coverage of the program to new geographic areas (Anne 

Arundel, Garrett and Alleghany counties) and add the Stanford Diabetes model to the current 

program offered. Project goals include 1) providing the CDSMP to approximately 1,700 new 

seniors across the state, 2) targeting low-income, minority and limited-English speaking 

persons over age 60 years, 3) implementing an effective delivery system for evidence-based 

health promotion programs while ensuring optimum fidelity, quality assurance levels and 4) 

expanding and strengthening our key partnerships. Maryland will bring CDSMP to the grant 

target population by training a diverse cadre of master trainers and providing employment for 

evidenced-based health program coordinators. Forming unique partnerships at the state and 

local levels with a new focus on the Stanford CDSMP Diabetes model will demonstrate an 

effective delivery infrastructure and have a real impact on the health status of seniors across 

the state. 




Project Title: Massachusetts Chronic Disease Self Management Program 



Masschusetts Executive Office of Elderly Affairs 

1 Ashburton Place 


Contact 

Adam Frank 

Tel. No. (617) 727-9368 

Email: adam.frank@state.ma.us 



Fiscal 

Year 

Funding 

Amounts 









Total $1,141,783 

The Massachusetts Executive Office of Elder Affairs (Elder Affairs), in partnership with the 

Massachusetts Department of Public Health (MDPH), seeks to implement the Massachusetts 

Chronic Disease Self-Management Program (CDSMP Project) to strengthen and sustain the 

statewide infrastructure to deliver CDSMP to older adults in Massachusetts. The project will 

include community-based collaborative networks led by Elder Services of the Merrimack 

Valley (ESMV) to implement the Stanford CDSMP and Tomando Control de su Salud 

(Tomando). The goal of the project is to establish a sustainable system to ensure statewide 

access for older adults to participate in quality Chronic Disease Self-Management Programs. 

The approach is to build community-based collaborative networks to deliver CDSMP and an 

infrastructure to ensure quality and fidelity. The objectives are: 1) to expand the 

infrastructure to support the statewide delivery of CDSMP; 2) to reach at least 1,713 older 

adults to participate in CDMSP or Tomando, and for these participants to report improved 

health; and 3) to improve sustainability of the statewide infrastructure for the delivery of 

CDSMP throughout the aging, public health, and health care networks. The expected 

outcomes are: 1) to have: CDSMP as an integral part of the health and long-term supports 

systems; 2) two regions of the state sponsor CDSMP networks; and 3) 1,713 older adults, 

including low income, minority and limited English speaking seniors benefit from participation 

in CDSMP. The CDSMP Project products are a quality assurance program; memoranda of 

understanding and contracts with public and private sector organizations; quarterly reports; 

evaluation results; website; articles for publication; and data on group leaders and 

participants. 




Project Title: Follow the PATH: Older Michiganians taking Personal Action 

Toward Health 



Michigan Department of Community Health 

Office of Services to the Aging 

329 S. Walnut 

Lansing, MI 48913 

Contact: 

Sherri King 

Tel. (517) 373-4064 

Email: kings1@michigan.gov 

AoA Project Officer: Sharon Skowronski 


Year Amount 


Total $1,106,479 


The Michigan Office of Services to the Aging (OSA), the Medical Services Administration 

(Medicaid) (MSA) and the Michigan Department of Community Health’s Division of Chronic 

Disease and Injury Control (DCDIC) are partnering to strengthen and enhance the existing 

statewide Michigan Partners on the PATH (MIPATH) infrastructure by improving the logistical 

and operational functionality of local and regional coalitions to facilitate the integration and 

embedding of evidence based disease prevention programming into the local aging and 

public health networks. This will be done through: 1) recruiting new statewide partners, 

including Aging and Disability Resource Center (ADRC) representation, medical 

schools/health care provider networks, and representatives from the disability networks; 2) 

designating AAAs as the local lead agencies and having them work with either their Planning 

and Service Area (PSA) based coalition or the a larger MIPATH Regional Coalition to 

develop a business plan, market and recruit older adults who are in the target group; and 

fund workshops within their PSA regions; 3) creating a statewide communications network 

that will get information about CDSMP to older adults and those that work with them; 4) 

creating a system to monitor fidelity; and 5) to research and develop sustainable funding 

streams. The expected outcomes of this project include 10 recruiting 3,380 older adults to 

attend CDSMP workshops throughout the state; 2) recruiting graduates of the programs to 

become leaders; and 3) creating a logistical system on a local level to maintain workshop 

offerings on a regular basis. Workshops will be given in sufficient numbers so participants 

will not have to travel more than 30 minutes to attend a workshop. 




Project Title: Minnesota's Chronic Disease Self-Management Program 



Minnesota Department of Human Services 


540 Cedar St. 

P.O. Box 64976 

St. Paul, MN 55164-0976 

Contact 

Kari Benson 

Tel. No. (651) 431-2566 

Email: kari.benson@state.mn.us 


Fiscal 

Year 

Funding 

Amounts 









Total $600,000 


The goal of the Minnesota Board on Aging and Minnesota Department of Health is to work 

with public and private partners at the state and community levels to build a sustainable 

statewide infrastructure to deliver the Stanford Chronic Disease Self-Management Program 

(CDSMP). Over the last several years, Minnesota has built a strong foundation to deliver 

evidence-based health promotion, falls prevention and chronic disease self-management 

programs. Though limited in geographic scope and participant reach, this infrastructure has 

proven successful in delivering these programs. The objectives of this initiative are to: 1) 

expand the availability of CDSMP statewide; 2) increase the reach of CDSMP statewide; 3) 

refine and expand the fidelity monitoring and quality assurance systems statewide; 4) build 

regional coordination infrastructure to support statewide delivery of CDSMP; and 5) build 

state, regional and local public-private coalitions to ensure long-term sustainability of 

CDSMP. The outcomes that are expected from the proposed initiative include: 1) at least 

800 participants having completed at least four workshop sessions by March 2012; 2) a 

significant proportion of CDSMP participants low-income; 3) most participants being age 60 

and older; 4) an increase in participants of non-white populations, 5) and positive reports of 

the course and of self-reported health by participants. The products of this initiative include 

participant and program data, narrative reports of progress, financial reports, workshop 

evaluation surveys, and webinars produced collaboratively by local agencies and CDSMP 

host organizations. 




Project Title: Mississippi Chronic Disease Self-Management Program 



Mississippi Department of Human Services 


750 North State St. 

Jackson, MS 39202 

Contact 

Danny George 

Tel. No. (601) 359-4925 

Email: danny.george@mdhs.ms.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $400,000 


The Mississippi Department of Human Services, the Division of Aging and Adult Services, in 

collaboration with the Mississippi Department of Health, the Mississippi Area Agencies on 

Aging, the Mississippi Division of Medicaid and Valley Services, Inc., will implement the 

Stanford Chronic Disease Self-Management Program (CDSMP) and the Stanford Diabetes 

Self-Management Program (DSMP) to face the challenge of increasing demands for social, 

health, and long-term care services for the over 60 population in Mississippi. The goal is to 

provide the six-week course to an estimated 500 seniors sixty years or older and slow the 

increasing rate of morbidities and moralities associated with chronic disease in Mississippi. 

The objectives of the project include: 1) collaborating with key partners to develop strong 

local community partnerships; 2) assisting in establishing memoranda of understanding with 

strategic partners; 3) supporting regular data analysis; 4) collaborating on strategies to report 

progress to key stakeholders, 5) collaborating on strategies to integrate CDSMP into the 

routine workflow of local programs; 6) educating program participants about the personal risk 

factors associated with chronic disease; 7) identifying pre-post instruments to measure levels 

of participant knowledge; 8) integrating feedback tools; and 9) increasing health lifestyle skills 

in participants that will assist them in managing their chronic conditions. The anticipated 

outcomes of the project include: 1) participants’ improved self-management of their health 

through learning to set attainable goals; 2) increased ease in daily activities; 3) increased 

communication with their health care providers; 4) enhanced health status; 5) better 

healthcare system utilization; and 6) increased self-efficacy. The products of this intervention 

will include a final report containing a blueprint for replication of the project along with 

significant results and findings; surveys, questionnaires, and interviews of staff and 

participants. 




Project Title: Improvement in Self-Management of Chronic Diseases Among 

Older Adults 




PO Box 570 920 Wildwood Drive 



Year Amount 


Contact: 

Brad Hall 

Tel. (573) 522-2806 

Email: brad.hall@dhss.mo.gov 



Total $632,864 

The Missouri Department of Health and Senior Services (DHSS), which includes the state 

unit on aging and the public health department, will collaborate with the state Medicaid 

program, and Missouri HealthNet, to support the implementation of the Stanford Chronic 

Disease Self-Management Program (CDSMP) in Missouri communities. This grant will build 

on public, private and community collaborations and partnerships achieved previously in a 

successful implementation of CDSMP. Area Agencies on Aging, local public health agencies 

and regional arthritis centers will collaborate locally to implement the Stanford program. 

(DHSS) will work with state agencies and key stakeholders groups to expand Missouri’s 

capacity to deliver the Stanford CDSMP including arrangements for training CDSMP trainers 

and leaders, collaborations to schedule and conduct the CDSMP courses at various locations 

and times that are convenient for the public, and routinely collect and report data. Project 

objectives are: 1) to increase the number of Stanford CDSMP programs in 30 communities; 

2) assist 925 older Missourians to complete the program; and 3) increase the number of state 

and local partners that implement the CDSMP or refer their clients to the programs. 




Project Title: Nebraska American Recovery and Reinvestment Act Living Well 

Program 




301 Centennial Mall So., P.O. Box 95026 

Lincoln, NE 68509-5026 


Year Amount 


Contact: 

Jamie Hahn 

Tel. (402) 471-3493 

Email: jamie.hahn@nebraska.gov 



Total $200,000 

The Nebraska Department of Health and Human Services will strengthen the state and local 

capacity to coordinate, deliver, and sustain its Living Well program statewide. Living Well is a 

Chronic Disease Self-Management Program (CDSMP) which enables older adults with 

chronic conditions to improve the quality of their lives while living independently. This will be 

accomplished through the: 1) development of a statewide and local infrastructure and 

delivery system for the Living Well Program; 2) creation of a network of Living Well English 

and Spanish Leaders statewide; 3) enhancing the relationship between the state’s Area 

Agencies on Aging and local public health departments; and 4) enhancing the relationship 

between the Nebraska Department of Health and Human Services State Unit on Aging, 

Medicare Agency, and Division of Public Health, Community Health Section programs. The 

Nebraska Living Well Program will strive to provide the Living Well program to a minimum of 

400 older adults (60+), of which 75 will represent minority populations and 125 will represent 

low income individuals. We will utilize the partner networks of the Area Agencies on Aging, 

local public health departments, various programs within the Nebraska Department of Health 

and Human Services’ Division of Public Health, Community Health Section, and other 

community-based service organizations to recruit leaders and participants to the Living Well 

workshops. We will also work with our Medicare certified rural health clinics, the federally 

qualified health centers, and Indian Health Services to make the Living Well program 

available to their patients. 




Project Title: Nevada American Recovery and Reinvestment Act Chronic Disease 

Self Management Program 



Nevada Department of Health and Human Services 

Aging and Disability Services Division 

3416 Goni Rd., Suite 132 


Contact: 

Jeff Doucet 

Tel. (702) 486-3545 

Email: jsdoucet@adsd.nv.gov 



Year Amount 


Total $200,000 


The Nevada Chronic Disease Self Management Program (CDSMP) will develop the capacity 

of the state and its communities to systematically deliver evidence-based prevention 

programs that address chronic conditions and other health risks among seniors, to help them 

maintain and improve their health status and independence. The goal of the Nevada CDSMP 

project is to improve the health of older adults in Nevada who have chronic conditions, so that 

they may achieve the best quality of life while maintaining their independence. Objectives 

include: 1) strengthening and significantly expanding existing capacity to deliver CDSMP and 

other evidence-based programs statewide; 2) developing and maintaining a communitybased 

collaborative network to support a statewide distribution system for Nevada to deliver 

CDSMP at the local level; 3) developing and maintaining a quality assurance component, to 

ensure the proper replication and fidelity of the Stanford CDSMP; and 4) embedding the 

aforementioned into the State of Nevada’s system to provide community-based services and 

supports to older adults. The Nevada Aging and Disability Services Division (ADSD) will 

serve as the lead agency for the project and will work closely with the Nevada State Health 

Division (HD) and the Nevada Medicaid Agency to provide project management, monitoring, 

evaluation and continuous quality improvement. Local partners are the Southern Nevada 

Health District and the Washoe County Health District Clark and Washoe Counties. 

Community partners will include the St. Rose Dominican Hospitals (SRDH) in Clark County 

and Saint Mary’s Regional Medical Center (SMRMC) to deliver the Stanford CDSMP to 300 

Nevadans, with special emphasis on reaching underserved populations such as low income 

Hispanic and African Americans in their respective communities. 




Project Title: New Hampshire American Recovery and Reinvestment Act Chronic 

Disease Self-Management Project 



New Hampshire Department of Health and Human Services 

Division of Public Health Services 

29 Hazen Drive 

Concord, NH 03301-6504 

Contact: 

Kathleen Berman 

Tel. (603) 271-5172 

Email: kberman@dhhs.state.nh.us 



Year Amount 


Total $200,000 


The gap between current and ideal availability of Chronic Disease Self Management (CDSM) 

programs in New Hampshire (NH) is substantial and the population that could benefit from 

CDSM is significant. Current capacity to deliver CDSM in NH is limited but could increase 

rapidly based on foundation-building that the NH Department of Health and Human Services 

(NH DHHS) has undertaken during the last several years. Both the NH DHHS Bureau of the 

New Hampshire (NH) Elderly and Adult Services (BEAS) and Bureau of Prevention Services 

(BPS) will support a coordinated plan to deliver CDSM programs to elderly and vulnerable 

populations in all NH counties. The partners will establish an Action Learning Collaborative, 

which will use outcomes and cost/benefit data from the project to influence policy and 

systems change. Collaboration began in 2006 when BEAS implemented a Senior Wellness 

Initiative in New Hampshire senior centers and BPS established a cross-agency Vulnerable 

Populations Work Group with BEAS involvement. The BPS Asthma and Diabetes Programs 

have since sponsored initial Stanford Chronic Disease Self-Management Program 

(SCDSMP) Master Training. The partners’ goal from the outset of this effort has been to 

develop CDSMP capacity statewide which can be created with NH’s small size and wellintegrated 

system of an existing network of senior service agencies affiliated with BEAS, 

including the NH Association of Senior Centers, ServiceLink Aging and Disability Resource 

Center (ADRC) sites, congregate meal sites and senior housing sites offering CDSMP 

workshops. The proposed project will also engage in its network Community Health Centers 

and primary care practices for referrals to CDSMP. 




Project Title: Integrating the Chronic Disease Self-Management Program into 

New Jersey's Community-Based Long-Term Care System 




240 W. State St. 

P.O. Box 360 

Trenton, NJ 08608 - 1002 

Contact 

Geraldine MacKenzie 

Tel. No. (609) 943-3499 

Email: geraldine.mackenzie@doh.state.nj.us 


Fiscal 

Year 

Funding 

Amounts 









Total $974,835 


The New Jersey Department of Health and Senior Services’ goal is to integrate the Chronic 

Disease Self-Management Program (CDSMP) as a key component of the State’s communitybased 

long-term care system. Over the past three years, DHSS and its state-level and 

community partners have established a strong platform for the delivery of CDSMP and other 

evidence-based programs (EBPs). The objectives are to: 1) increase access to CDSMP and 

the Diabetes Self-Management Program (DSMP) throughout the state with a focus on 

reaching minorities, individuals who speak limited English, and those with low incomes; 2) 

develop an infrastructure to support sustained referral to and delivery of CDSMP and DSMP; 

and 3) enhance program administration by formalizing partnerships, ensuring program 

fidelity, strengthening data collection and evaluation, and developing a statewide 

sustainability plan. Models for program delivery/referral will be implemented in multiple 

service networks including the Aging and Disability Resource Center, primary care and 

chronic disease programs. Agencies/associations able to deliver large numbers of 

workshops and oversee peer leaders will be nurtured, including those that can do so in 

languages other than English. Expected outcomes include: 1) a minimum of 1,462 workshop 

completers; 2) 45% of participants will be minorities, 25% low-income, and 25% will be limited 

English-speaking; 3) Improvements in self-reported health status and number of poor health 

days of participants; 4) Improvements in health outcomes related to routine diabetes checks 

(A1c levels, foot checks, and eye checks). Products will include documentation of staff and 

participant strengths and weaknesses, materials assessing the success of CDSMP 

integration, and a sustainability plan for CDSMP and other EBPs. 




Project Title: Expansion of New Mexico’s Arthritis Program Using Stanfords 




New Mexico Department of Health 

5301 Central Ave NE Suite 800 

Albuquerque, NM 87108 


Year Amount 


Contact: 

David Vigil 

Tel. (505) 841-5836 

Email: david.vigil1@state.nm.us 



Total $252,583 

The New Mexico (NM) Department of Health (DOH) Chronic Disease Prevention and Control 

Bureau’s (CDPCB) Arthritis Program will serve as the lead agency in delivering Stanford 

University’s Chronic Disease Self-Management Program (CDSMP) in partnership with State, 

regional and local organizations. The purpose of this 24-month project is to build on and 

expand the Arthritis Program’s current efforts in delivering CDSMP in New Mexico. The goal 

is to enable CDSMP participants to build the self-confidence to assume a major role in 

maintaining their health as well as managing their chronic health condition(s). The Arthritis 

Program will work closely with the New Mexico Aging and Long Term Services Department 

(ALTSD) through development, strategic planning and implementation of the CDSMP. The 

Southern Area Health Education Center (SoAHEC), Montañas del Norte Area Health 

Education Center (MdN AHEC), and the City of Albuquerque, Department of Senior Affairs 

(COA DSA) will serve as the key system partners for the delivery of the CDSMP in targeted 

communities. New Mexico plans to reach at least 500 older adults statewide with the 

CDSMP. System partners will focus on low income, minority and limited English-speaking 

older adults (ages 60 and older). To achieve these outcomes, programmatic efforts will be 

focused on aligning partners to maximize not only resources, but expertise. Partners will 

support CDSMP delivery by leveraging partnerships, creating credibility, and using various 

communication strategies. 




Project Title: New York State American Recovery and Reinvestment Act Chronic 






Albany, NY 12223-1251 


Year Amount 


Contact: 

Marcus Harazin 

Tel. (518) 473-5705 

Email: marcus.harazin@ofa.state.ny.us 



Total $1,190,610 

The New York Office for the Aging and its partners will establish regional delivery 

collaboratives forming a network to share resources, manage local recruitment, marketing, 

delivery, treatment fidelity and sustainable delivery of the Chronic Disease Self-Management 

Program (CDSMP). Project goals are to: 1) Serve 5,000 community-living older adults with 

chronic diseases; 2) engage providers already delivering CDSMP in a statewide system; and 

3) build a regional infrastructure to offer and sustain high quality delivery of CDSMP and 

other evidence-based health programs. Objectives are to: 1) build six CDSMP regional local 

delivery collaboratives that include aging service providers, physicians, other health care 

providers, NY Connects (NY’s ADRC), and non-traditional partners; 2) train 80 master 

trainers and 300 peer leaders; 3) serve 5,000 residents of NYS aged 60+, yielding 3,700 

completers of CDSMP including 800 Latino and English as a Second Language completers 

of Tomando Control and the Diabetes Self-Management Program; and 4) develop state and 

regional business plans for sustaining CDSMP. Features include referrals by physicians, 

health networks and NY Connects; reimbursement through Older Americans Act, Medical 

Home, Medicaid and private insurance funding and local agencies leveraging new and 

existing capacity expanding access; and fidelity and quality assurance led by statewide T- 

trainers building towards regionally-based efforts. 




Project Title: ARRA Chronic Disease Self-Management Program 





Raleigh, NC 27699-2001 

Contact 

Audrey Edmisten 

Tel. No. (919) 733-8390 

Email: audrey.edmisten@dhhs.nc.gov 



Fiscal 

Year 

Funding 

Amounts 









Total $1,006,537 

The purpose of this grant is to implement Stanford University's Chronic Disease Self- 

Management Program (CDSMP) and Diabetes Self-Management Program (DSMP) through a 

partnership between the North Carolina Division of Aging and Adult Services (DAAS) and the 

Division of Public Health (DPH). The state's goal is to adapt CDSMP to a smaller scale, 

making it accessible to seniors throughout the state in 17 Area Agency on Aging (AAAs) 

regions, and will expand the DSMP to ten AAA regions, where over 50% of the State’s older 

adults reside. Our objectives are to: 1) reach a total of 2,995 participants in CDSMP and/or 

DSMP, and target low-income, minority, and/or rural older adults; 2) work with at least three 

diverse implementation settings in each of the seventeen AAA regions to deliver the 

programs; 3) assure that all sites will deliver the program components as intended ¿ taking 

steps to ensure fidelity and quality; 4) track processes at the state and regional levels; 5) 

expand the statewide infrastructure, utilizing AAAs as hubs of regional activities supporting 

ongoing sustainability and quality assurance; and 6) establish regional committees of diverse 

and dedicated stakeholders to help shape and support the program implementation. The 

expected outcomes include: 1) improvements in exercise, cognitive symptom management, 

communication with physicians, self-reported general health; 2) reduction in health distress, 

fatigue, disability, and social/role activities limitations. Products will include: a corps of 

CDSMP and DSMP Master Trainers and Lay Leaders, data collection forms, fidelity 

monitoring tools and training, a CDSMP Business Plan, and a statewide marketing campaign. 




Project Title: Ohio's Chronic Disease Self-Management Program/ Diabetes Self- 

Management Program Statewide Expansion Initiative 






Contact 

Marc Molea 

Tel. No. (614) 752-9167 




Fiscal 

Year 

Funding 

Amounts 









Total $1,000,000 

The Ohio Department of Aging (ODA), in cooperation with the Ohio Department of Health’s 

Office of Healthy Ohio (ODH), area agencies in aging (AAAs), and local partners 

(county/municipal health departments and community-based human services organizations), 

propose the goal of making the Chronic Disease Self-Management Program (CDSMP) and 

Diabetes Self-Management Program (DSMP) workshops available to older Ohioans and their 

caregivers on a statewide basis. This need for statewide expansion is supported by a high 

prevalence of chronic disease in Ohio; limited coverage and availability of current 

CDSMP/DSMP initiatives; and limited funds to implement evidence-based disease prevention 

(EBDP) programs. To support statewide expansion, ODA and ODH have set the following 

objectives: 1) develop a statewide training and quality/fidelity control infrastructure; 2) expand 

the availability of CDSMP and make DSMP available by funding AAAs/local partners to 

conduct CDSMP and DSMP workshops; 3) identify and fund new partners and pathways to 

support involvement of additional organizations that will target hard to serve populations and 

health disparities; 4) implement strategies to sustain and support the continued availability of 

CDSMP and DSMP; and 5) provide continued support to CDSMP/DSMP participants after 

they have completed workshops. Outcomes will include: 1) 2 new T-trainers, 20 new Master 

Trainers and 170 Lay Leaders; 2) 2,975 workshop graduates; 3) introduction of CDSMP into 

Cleveland and Cincinnati; 4) higher number of low-income and minority individuals 

participating in CDSMP/DSMP; and 5) expanded outreach to Medicaid eligible individuals, 

individuals with mental illness, caregivers, and veterans. Products will include an inventory of 

currently available master trainers and lay leaders, a revised participant survey form to 

include necessary data elements, and a database at ODA to track and monitor human 

capital. 




Project Title: The Living Longer, Living Stronger Project: Oklahoma's Self 

Management Expansion 







Year Amount 


Contact: 

Zachary Root 

Tel. (405) 522-3121 




Total $400,000 

The Oklahoma Department of Human Services Aging Services Division (OKDHS ASD), in 

partnership with the Oklahoma State Department of Health (OSDH), the Oklahoma Health 

Care Authority (OHCA), the Oklahoma Department of Corrections (ODOC) Area Agencies on 

Aging, local county health departments, and the Choctaw Nation of Oklahoma, will expand 

implementation of the Chronic Disease Self Management Program (CDSMP) and build upon 

our evidence-based intervention list with the introduction of the Diabetes Self Management 

Program (DSMP) into Oklahoma. OKDHS ASD, OSDH and the Choctaw Nation will take the 

lead in coordinating state efforts with lead local community organizations. The goal is to 

increase the quality of life and decrease the complications of chronic disease of Oklahomans 

over 60 years old by implementing CDSMP and DSMP. Objectives are to: 1) develop and 

sustain quality implementation of two evidence-based disease prevention programs for 

persons over 60; 2) improve collaboration among health, public health, and aging services 

network agencies; and 3) evaluate the program, document activities, and disseminate the 

results. Outcomes are: 1) to provide evidence-based disease prevention programs to 700 

persons over 60; and 2) sustain the program once federal funding ends. Participants will 

report: 1) improvements in self-rated health (15%); 2) decreased health distress (40%); 3) 

increased stretching and strengthening exercise (40%); 4) decreased use of medical services 

(5%); 5) increased use of pain-management techniques (50%); 6) program satisfaction 

(90%); 7) increased energy levels (40%); and 8) increased endurance in exercise (25%). 

This project will produce a final report; marketing materials; articles for publication; participant 

data; models for urban, rural and tribal regions; and presentations for national conferences. 




Project Title: Oregon American Recovery and Reinvestment Act Chronic Disease 

Self-Management Program Project 





676 Church Street 


Contact: 

Elaine Young 

Tel. (503) 373-1726 

Email: elaine.young@state.or.us 



Year Amount 


Total $478,873 


The Oregon Department of Human Services (DHS) State Unit on Aging will support the 

health and independence of the state’s aging population by reaching older adults with 

sustainable, quality chronic disease self-management programs. At least 800 older adults 

age 60 and older will complete Stanford’s Chronic Disease Self-Management Program 

(called Living Well with Chronic Conditions in Oregon) or Tomando Control de su Salud 

(Tomando) program, and DHS will increase capacity to sustain quality self-management 

programs through systems of regional coordination and fidelity monitoring, identification of 

sustainable funding sources, and expanded reimbursement options. DHS will partner with 

two Area Agencies on Aging with histories of collaboration with local health departments and 

community organizations that serve older adults to provide Living Well/Tomando programs. 

Within DHS, the State Unit on Aging and Public Health Division will collaborate to support 

statewide training and technical assistance to continue to develop statewide capacity to offer 

programs. DHS will work with the two areas and the Division of Medical Assistance 

Programs to develop systems for regional sustainability. Project objectives are: 1) between 

March 31, 2010 and March 30, 2012, 800 older adults will have completed a Living Well or 

Tomando program; 2) by March 30, 2012, ensure that low income, rural, Latino, and Native 

American older adults have access to Living Well/Tomando programs, and that at least 10% 

of participants are Latino or Native American older adults; 3) by March 30, 2012, develop 

regional infrastructure in two areas of the state to provide coordinated, quality Living 

Well/Tomando programs that reach older adults; 4) by March 30, 2012, develop systems to 

support sustainability of Living Well/Tomando programs. 




Project Title: Deploying Evidence-Based Chronic Disease Self-Management 

Programs (CDSMP) That Empower Older Adults 



Pennsylvania Department of Aging 

555 Walnut Street 5th FL 

Harrisburg, PA 17101-1925 


Year Amount 


Contact: 

Jack Hillyard 

Tel. (717) 425-5716 

Email: jhillyard@state.pa.us 


Total $1,000,000 


The Pennsylvania Departments of Aging and Health will implement and expand the delivery 

of the Stanford University Chronic Disease Self-Management Program to empower older 

Pennsylvanians with chronic diseases to maintain and improve their health status. Four Area 

Agencies on Aging, Allegheny County Area Agency on Aging; Berks County Office on Aging; 

Cambria County Area Agency on Aging; and Philadelphia Corporation for Aging, will be local 

lead agencies to administer the program. They were selected by using a combination of the 

following community factors: 1) a high prevalence of chronic diseases in the Commonwealth; 

2) economic distress; and 3) demographic density of low-income, minority and limited English 

speaking older adults. This effort builds a foundation of community-level partner networks 

involving our respective aging and public health affiliates and offers an opportunity for local, 

state and federal agencies to meaningfully strengthen cross-departmental healthcare-related 

efforts. The overall goal is to improve the ability of 3,309 older adults to maintain their health 

and manage their chronic health conditions. Activity is targeted to low-income, minority and 

limited English-speaking older adult populations. The project objectives are to: 1) document 

the impact of CDSMP on participant health behavior, disability and role functioning and selfreported 

health care; 2) identify state and local program integration strategies to ensure 

sustainability; and 3) demonstrate a replicable model of collaboration among area agencies 

on aging, local health departments, community service providers and health care 

organizations. 




Project Title: Puerto Rico Chronic Disease Self-Management Program 



Puerto Rico Department of Health 

PO Box 70184 

San Juan, PR 00936-8184 


Year Amount 


Contact: 

Abraham Rivera 

Tel. (787) 977-2156 

Email: abrahamrivera@salud.gov.pr 



Total $400,000 

The Puerto Rico Department of Public health (DOH) will implement the Stanford University 

evidence-based Chronic Disease Self Management Program (CDSMP) to empower older 

people with chronic diseases in Puerto Rico to maintain and improve their health status and 

help maintain their independence in the community and reduce health care costs. The DOH 

and the Office of the Ombudsman for the Elderly (OOE) will support the project goal of 

implementing an evidence based PRCDSMP for the population 60 years and older with 

chronic conditions by providing self management skills to maintain healthy and active 

lifestyles. The expected outcomes for the Puerto Rico CDSMP are that adults 60 years or 

older who participate and complete the program will report having better strategies for coping 

with their chronic conditions, specifically: 1) improvements in self rated health; 2) decrease in 

health distress; 3) increase exercise; and 4) decrease in self reported hospitalizations and in 

self reported health care utilization. The program will serve a minimum of 500 hundred older 

adults with chronic conditions using a team of trainers certified by Stanford University to 

implement the program in each health region considering chronic disease prevalence. 

Partnerships with public, private and community organizations will provide technical 

assistance, collect data, implement an evaluation plan and fulfill reporting requirements. The 

CDSMP will coordinate with Aging Resource Centers, healthcare providers, health insurance 

agencies, the Puerto Rico Health Services Administration, Chronic Disease Division, Healthy 

Communities, Health Promotion and Education Programs and others, to identify and refer 

potential participants. The trainers and leaders to be certified include health educators, social 

workers, nurses, community outreach workers and chronic disease patients willing to be 

trained and implement the program in their community. An awareness plan and collaboration 

agreements will be completed to assure CDSMP continuance. 




Project Title: Living Well Rhode Island: A Model to Improve Chronic Disease Self- 

Management in Seniors 



Rhode Island Department of Health 

3 Capitol Hill, Room 409 

Providence, RI 02908 


Year Amount 


Contact: 

Ana Novais 

Tel. (401) 222-5117 

Email: Ana.Novais@health.ri.gov 



Total $200,000 

Rhode Island (RI) proposes to expand and strengthen its existing capacity to deliver Chronic 

Disease Self-Management Programs (CDSMP) among seniors. RI’s two current CDSMP 

programs are the Stanford Chronic Disease Self Management Program and Tomando 

Control de su Diabetes. Living Well Rhode Island: A Model to Improve Chronic Disease Self- 

Management in Seniors, will expand the delivery infrastructure for these two programs, by 

working with senior centers in Providence County which has the largest population of 

residents 60 and over of which the minority population is approximately 10,372. This 

represents an estimated 8.5 percent of the county’s total population of 124,635 seniors. At 

least 65% of these seniors have a risk factor for or diagnosed chronic disease. The RI 

Department of Health will serve as the lead agency for this application and will continue its 

strong collaboration with the RI Department of Elderly Affairs, and the Medicaid Office of the 

Department of Human Services to improve and sustain CDSMP. An integral collaboration 

will be established with RI’s statewide Aging and Disability Resource Center. Currently, RI 

has 29 Master Trainers of which 26 are bi-lingual and 116 Leaders, of which 39 are bilingual. 

This work force is guided and governed by an 18 member Steering Committee and four Task 

Groups (Policy, Recruitment, Assessment and Fidelity), which meets quarterly, and a 142 

member Coalition, which meets bi-annually, and provides updates, shares best practices, 

and discusses barriers and solutions. Through this grant, RI will: 1) provide CDSMP to a 

minimum of 500 Providence County seniors, focusing on low-income, minority, and limited 

English speaking seniors; and 2) strengthen the existing CDSMP infrastructure to provide 

evidenced-based prevention programs for seniors so that programs can be sustained postfunding. 




Project Title: Expansion of Chronic Disease Self-Management Program in 

South Carolina 







Contact 


Tel. No. (803) 734-9939 



Fiscal 

Year 

Funding 

Amounts 









Total $750.000 


The Lieutenant Governor’s Office on Aging (LGOA), in partnership with the South Carolina 

Department of Health and Environmental Control (DHEC), will implement both a Chronic 

Disease Self-Management Program (CDSMP) and the Arthritis Foundation Self-Help 

Program, targeting persons 60 and older and younger persons with disabilities, especially 

vulnerable and underserved populations. The goal of this project is to reduce the burden and 

impact of chronic disease in South Carolina and to improve the quality and years of life of 

older adults. The objectives of this project are to: 1) increase access to and use of CDSMP 

and the Arthritis Foundation Self-Help Program; 2) developing an integrated statewide 

infrastructure to support their quality and expansion; 3) implement the two programs in three 

new, underserved geographic regions; 4) expand the programs in the original three 

Administration on Aging grantee regions; 5) to strengthen the statewide infrastructure for all 

evidence based programs; 6) increase the collaboration between state and local partners to 

effectively expand and evaluate the two programs; 7) to solidify and broaden system-level 

and infrastructure changes initiated through other projects; and 8) to further collaborative 

efforts already underway with community and faith-based partners. Expected outcomes are: 

1) to reduce the burden and impact of chronic disease in South Carolina; and 2) improve the 

quality and years of life for older adults and individuals with disabilities in South Carolina. 

Products will include evaluations of program reach, number of completers, demographics, 

quality (fidelity), and participant satisfaction; quarterly, semi-annual, and annual reports; and 

written processes for EBP dissemination at state and region level. 




Project Title: Chronic Disease Self-Management Programs 







Year Amount 


Contact: 


Tel. (615) 741-2056 




Total $800,000 

The Tennessee Commission on Aging and Disability (TCAD) will partner with State, 

Regional, and local partners to achieve the goal of implementing and sustaining the Stanford 

Chronic Disease Self-Management Program (CDSMP) and enhancing the Arthritis Self-Help 

Program (ASHP) to reach a minimum of 1,200 older Tennesseans. The objectives are to: 1) 

implement and manage the CDSMP in 6 regions; 2) enhance ASHP by training additional 

leaders and providing the program to rural counties not currently being served; 3) build 

capacity by developing a cadre of leaders to provide and maintain the self-management 

programs; 4) make CDSMP more accessible to an increased number of older adults; 5) 

embed the programs through the infrastructure and delivery systems currently in place; and 

6) empower older adults with chronic disease to maintain a healthy lifestyle through selfmanagement 

and to avoid placement in nursing home facilities as a direct result of chronic 

disease through participation in the CDSMP/ASHP. TCAD’s partners for this project are the 

Tennessee Department of Health, the Department of Finance and Administration, Bureau of 

TennCare, Arthritis Foundation of Tennessee, University of Tennessee Extension, and the 

Area Agencies on Aging and Disability in Greater Nashville, East Tennessee, First 

Tennessee, Southeast Tennessee, and Northwest Tennessee and Meritan in Memphis. 

Coordinators will conduct outreach and recruit potential participants, program leaders will be 

identified and trained, and courses will be delivered. Quality assurance activities use the RE 

AIM (Reach, Efficacy/Effectiveness, Adoption, Implementation, Maintenance) framework and 

the implementation components to ensure fidelity of implementation. 




Project Title: Texas Healthy Lifestyles 2010-12 




Access and Intake 

701 West 51st Street 

Austin, TX 78751-2312 

Contact: 

Christy Fair 

Tel. (512) 438-5471 




Year Amount 


Total $1,000,000 


Texas Healthy Lifestyles 2010-12 (TXHL) will dramatically increase the capacity of Texas 

state and local partnerships to deliver Chronic Disease Self-Management Programs 

(CDSMP) and Diabetes Self-Management Programs (DSMP) as well as explore the creation 

of long-term, system-level infrastructure changes to improve the delivery of information and 

training to Texans living with chronic disease. The project will involve a partnership including 

the Department of Aging and Disability Services (DADS), the Department of State Health 

Services (DSHS), the Health and Human Services Commission (HHSC), HHSC’ s Office of 

Border Affairs, and a coalition of area agencies on aging (AAAs), encompassing 67 counties. 

HHSC will work to identify and engage through its Texas Health Management Program 

(HMP) chronically ill Medicaid clients. DADS and HHSC, in conjunction with the State’s HMP 

contractor, will work to minimize Medicaid expenses for delivering CDSMP/DSMP to dual 

eligible clients with chronic disease and explore the feasibility of offering CDSMP/DSMP as a 

Medicaid benefit. Local partners chosen through a competitive process have committed to 

delivering CDSMP and DSMP in both English and Spanish to 4,098 individuals, including 

those from major metropolitan areas, rural East Texas and two tribal entities. The projected 

number of course completers is 2,975. Partners have committed to creating local 

partnerships and developing funding options to sustain its projects beyond the initial two-year 

period including at least a ten percent match in cash or in-kind services to this initial funding. 

A Texas A&M School of Rural Public Health evaluation team will assist the state in the 

development of a standardized evaluation protocol, training with the state and participating 

sites, data analysis, report writing, and feedback to key stakeholders. 




Project Title: Development and Expansion of the Chronic Disease Self- 

Management Program Infrastructure in Utah 



Utah Department of Health 

PO Box 142001 

288 North 1460 West 


Contact: 

Nathan L. Peterson 

Tel. (801) 538-9458 

Email: nathanpeterson@utah.gov 



Year Amount 


Total $298,660 


The project goal is to increase participation in Chronic Disease Self-Management Programs 

(CDSMP) in Utah by developing and expanding the current infrastructure through the 

development of partnerships with area agencies on aging, local health departments and 

community-based organizations serving older adults to create a statewide distribution system 

to systematically deliver CDSMP interventions to senior citizens. Objectives include: 1) 

program completion from 1,200 older adults with chronic conditions through this AoA grant 

and an additional 800 through support of the Centers for Disease Control and Prevention 

(CDC) who participate in approved English and Spanish CDSMP models; 2) developing and 

expanding partnerships with six Area Agencies on Aging (AAA) and local public health 

networks; 3) increasing the number of trained leaders and master trainers; 4) addressing the 

special needs of seniors; and 5) developing a sustainable plan for systems-based CDSMP 

delivery. As a state currently funded by the CDC Arthritis Program, the approach will be to 

maintain program fidelity while significantly increasing the number of systems delivering 

CDSMP interventions. Partnerships within systems in areas of the state with greatest need 

and potential for reach the expansion of programs in Salt Lake County, which covers 

approximately 40% of adults over 60, and the Davis County and Mountainland AAA systems. 

New partnerships will includes the Southwest Utah region, which has an estimated reach of 

15% of the Utah population over 60; the Tooele County AAA to address the needs of a large 

county in northwest Utah; and the Central Utah Health District, to achieve statewide 

distribution. It is expected that the new infrastructure can reach 95% of Utah seniors. 




Project Title: Vermont Chronic Disease Self-management Program Collaborative 



Vermont Department of Health 

108 Cherry Street, Box 70 

Burlington, VT 05402 


Year Amount 


Contact: 

Robin Edelman 

Tel. (802) 863-7208 

Email: Robin.Edelman@ahs.state.vt.us 



Total $100,000 

The goal of Vermont’s program is to build the local infrastructure to implement evidencebased 

chronic disease programs to reduce the health and economic burden of chronic 

disease through the Stanford Chronic Disease and Diabetes Self-management programs. 

The Vermont Department of Health (VDH), in collaboration with the Department Disabilities, 

Aging and Independent Living (DAIL), Area Agencies on Aging (AAAs), and the hospitals 

statewide strive achieve this goal through the following objectives: 1) recruit 140 older adults 

and adults with disabilities to complete the program; 2) formalize the partnerships between 

the institutions such as local VDH District Offices, AAAs, and Vermont hospitals; and 3) 

ensure program fidelity through measures such as refresher trainings and program 

evaluations. The expected outcomes include: 1) improved self-confidence, 2) decreased 

emergency room utilization and lower number of avoidable hospitalizations among program 

completers; 3) implement program at senior meal sites and housing sites; and 4) increased 

collaboration with Medicaid case managers to identify and refer patients to the program. 




Project Title: Chronic Disease Self-Management Program/Diabetes Self- 

Management Program 




Department for the Aging 



Contact: 

Katie M. Roeper 

Tel. (804) 662-7047 

Email: katie.roeper@vda.virginia.gov 



Year Amount 


Total $1,046,084 


The Virginia Department for the Aging (VDA), in partnership with the Virginia 

Department of Health (VDH) and the Department of Medical Assistance Services (DMAS), 

proposes to build on the Commonwealth’s current Stanford Chronic Disease Self- 

Management Program (CESMP) and Diabetes Self Management Program (DSMP) initiative 

“You Can! Live Well Virginia!” These programs will be administered for older adults with 

chronic diseases through nine Area Agencies on Aging (AAAs) and ten Health Districts (to 

include 35 local health departments) and serve 49 cities and counties, reaching over 52% of 

the Commonwealth’s over 60 population. The project will assist older adults in managing 

their illnesses to improve their health status, increase quality of life, and prolong 

independence and ensure a sustainable delivery system for evidence-based programs is 

embedded into Virginia’s network of community-based supports for seniors. Expected 

outcomes include: 1) 2,136 individuals completing a CDSMP or DSMP; 2) 23 additional 

certified Master Trainers; 3) a minimum of 182 new trained Leaders; 4) a strengthened state 

and local infrastructure delivering evidence-based prevention programs; and 5) resource 

leverage and integration with current evidence-based prevention and aging services 

initiatives. VDA and VDH will provide technical assistance to community projects, coordinate 

and host Master Trainings, track outcomes, and lead sustainability planning. DMAS will 

administer communications with appropriate Medicaid waiver beneficiaries and foster 

partnerships with appropriate medical, insurance, and corporate entities. AAAs will provide 

community-wide coordination, program administration and lead community teams. 




Project Title: Washington State Communities Putting Prevention to Work:Chronic 





Aging and Disability Services Administration 

PO Box 45600 640 Woodland Square Loop SE 

Olympia, WA 98504-5600 

Contact: 

Marietta Bobba 

Tel. (360) 725-2618 

Email: bobbam@dshs.wa.gov 



Year Amount 


Total $652,582 


The Department of Social and Health Services (DSHS) in partnership with the Department of 

Health (DOH) will offer the Stanford University Chronic Disease Self Management Program 

(CDSMP) and Tomando Control de su Salud through four Area Agencies on Aging, as lead 

local organizations. The project will strengthen and significantly impact existing capacity to 

deliver CDSMP in Washington, reaching 2000 older adults (age 55 and older) yielding 1200 

course completers through a network of master trainers, lay leaders and partnerships with 

public/private organizations. This goal will exceed the targeted minimum CDSMP course 

completers required for Washington by 33%. Older adults with access barriers, such as 

language (Spanish, Korean, Vietnamese), culture (Tribes, immigrant/refugees) geographic 

remoteness or living in low income senior housing, will be targeted for inclusion in the 

workshops. This project will provide a foundation for development of a statewide 

dissemination and distribution infrastructure for CDSMP. Existing quality assurance methods 

will be implemented for continuous quality improvement including quarterly web based 

meetings and master trainer oversight to ensure fidelity. Multiple existing and new 

community level collaborations will serve as vehicles to form new partnerships for 

sustainability. This will be accomplished through local and state advisory workgroups, 

enhanced website development, statewide conferences, master trainer classes and feasibility 

studies to assist with dissemination methodology to expand reach. DSHS/ADSA will work 

with DSHS/Health and Recovery Services Administration (HRSA) to expand reimbursement 

for CDSMP to all adults with chronic conditions covered by the State Medicaid Plan. 




Project Title: West Virginia Chronic Disease Self Management Program 



West Virginia Department of Health and Human Resources 

State Capitol Complex, Building 3, Room 206 

Charleston, WV 25305 


Year Amount 


Contact: 

Joe Barker 

Tel. (304) 558-9103 

Email: joseph.l.barker@wv.gov 



Total $400,000 

The Bureau of Public Health (BPH) will partner with the Bureau of Senior Services (BoSS), 

Bureau for Medical Services (BMS), West Virginia University Center on Aging’s Rural Healthy 

Aging Research Network (WVU RHAN), Marshall University Center for Rural Health (MU), 

and the Partnership of African American Churches (PAAC) to develop a network to 

disseminate the Chronic Disease Self Management Program (CDMSP). This collaboration 

will address these objectives: 1) disseminate CDSMP/DSMP in all four AAA (Area Agency 

on Aging) regions in collaboration with Senior Citizen Centers, Aging and Disability Resource 

Centers (ADRCs), Federally Qualified Health Clinics (FQHCs), local health departments, and 

PAAC, to target 800 participants, including at least 80 African-Americans; 2) build the 

capacity in 30 organizations to implement CDSMP/DSMP through training 16 new master 

trainers and 32 new CDSMP/DSMP Course Leaders; 3) develop the capacity in organizations 

that serve minority populations by training at least 16 African-Americans; and 4) sustain the 

dissemination of CDSMP/DSMP by equipping two staff members in the BPH and three staff 

members in BoSS to provide leadership for supporting these programs throughout the state. 

The BPH in close partnership with BoSS will lead this statewide effort with guidance by a 

Steering Committee to explore collaborative sustainability options. CDSMP will be offered at 

five venues across the state including Senior Centers, ADRCs, FQHCs, local health 

departments, and the 22 churches members of PAAC. Further sustainability planning will be 

sought using West Virginia University School of Social Work and the West Virginia University 

Extension Service Community Outreach Education Service volunteers. MU will coordinate 

training efforts of Master Trainers, and Lay Leaders and provide yearly skill building 

seminars. WVU RHAN will serve as the project evaluator. 




Project Title: Wisconsin Chronic Disease Self Management Program 




1 W. Wilson Street P.O. Box 7850 

Madison, WI 53707-7850 


Year Amount 


Contact: 

Gail Schwersenska 

Tel. (608) 266-7803 

Email: gail.schwersenska@wisconsin.gov 

AoA Project Officer: Priti Shaw 


Total $810,328 

Under this grant, Wisconsin will complete statewide expansion of the Stanford Chronic 

Disease Self-Management Program (CDSMP) utilizing the existing aging and public health 

networks and in partnership with private health systems and health maintenance 

organizations. Special attention will be given to reaching Wisconsin’s Latino population by 

expanding Tomando Control de su Salud (Tomando), the Spanish version of CDSMP in 

Milwaukee and training leaders in two other Hispanic communities in Wisconsin. Using 

trained Native American master trainers, CDSMP will be expanded to at least five (5) of the 

11 federally recognized tribes. In total an estimated 1,600 individuals will participate in 

CDSMP workshops over the next two years. On the state level, the aging and public health 

partnership forged in other grants will continue and the Division of Health Care Access and 

Accountability (DHCAA), the Medicaid agency will join the partnership to provide access and 

outreach to both the community-dwelling older Medicaid population and its extensive provider 

network. This grant will provide funding for two new staff positions at the Wisconsin Institute 

for Healthy Aging (WIHA). These positions will be vital to establishing a permanent, 

sustainable home for evidence-based prevention programs. The WIHA will serve as a vital 

link to assuring the quality and fidelity by leading and coordinating the monitoring activities of 

these programs at the state, regional and local level. As part of the effort to maintain quality 

and fidelity, a consultant with experience in curriculum development utilizing the principles of 

adult learning will be engaged to assist in designing a leader refresher course based on the 

key elements of the Chronic Disease Self-Management Program. 


Chronic Disease Self Management Assistance Programs 

National Resource Center 

The Administration on Aging solicited applications in FY2010 for support of a National 

Resource Center to provide technical assistance and evaluation support for AoA and the new 

State Chronic Disease Self-Management Program (CDSMP) project recipients. The Center 

is expected to document the extent to which CDSMPs are being implemented with fidelity to 

their original research design and to strengthen the capacity of states and communities to 

sustain CDSMPs after their grant period. 


Program: Chronic Disease Self-Management Program National Center 

Grant Number: 90RC0042 

Project Title: Communities Putting Prevention to Work Chronic Disease Self- 

Management Program National Resource Center 



National Council on Aging, Inc 

1901 L Street, NW – 4thFloor 



Year Amount 


Contact: 

Wendy Zenker 

Tel. (202) 479-6618 

Email: Wendy.Zenker@ncoa.org 


Total $2,837,500 


The National Council on Aging (NCOA) will serve as the National Resource Center for the 45 

states, DC and Puerto Rico that received grants to promote wellness by deploying evidencebased, 

chronic disease self-management programs (CDSMP) targeted at older adults with 

chronic conditions. The Center’s goal is to work collaboratively with the Administration on 

Aging (AoA), the 47 states and territories funded by the Recovery Act, the aging services 

network and other stakeholders to develop the infrastructure, systems and support to sustain 

and expand CDSMP and other evidence-based programs. The objectives of the Center are 

to: 1) provide resources and tools that will assist states in meeting their goals; 2) develop 

and implement data collection systems to facilitate reporting; 3) assess and evaluate state 

performance in order to identify opportunities to improve performance; 4) document the 

extent to which CDSMPs are being implemented with fidelity to the original research design; 

5) strengthen the capacity of states and communities to sustain CDSMPs after the grant 

period ends; and 6) conduct a national study of participant outcomes. Project outcomes 

include: 1) state’s achievement of agreed upon goals to conduct programs that will result in 

over 50,000 participants attending and completing four out of six CDSMP workshops; and 2) 

integration of evidence-based and CDSMP programs into the state delivery and distribution 

system for services to older adults. The Center will also work to advance CDSMP national 

scaling though collaboration with other federal agencies, national organizations and 

stakeholders. The Center will produce materials to assist state grantees in achieving their 

goals, make these materials widely available through webinars, technical assistance calls, 

site visits, and a website; develop and implement a data management system to facilitate 

reporting, and issue a final report on the national study. 


Community Living Program 

AoA launched the Community Living Program (CLP) in the fall of 2007 which is designed to 

assist individuals who are at risk of nursing home placement and spend down to Medicaid to 

enable them to continue to live in their communities. The CLP grants are administered 

through the State Units on Aging (SUAs), in partnership with Area Agencies on Aging (AAAs) 

and in collaboration with community service providers, and other key long-term care 

stakeholders. Grants to SUAs encourage the Aging Services Network to modernize and 

transform the funding they receive under the Older Americans Act, or other non-Medicaid 

sources, into flexible, consumer-directed service dollars. It complements the Centers for 

Medicare and Medicaid Services (CMS) “Money Follows the Person Initiative” by 

strengthening the capacity of states to reach older adults before they enter a nursing home 

and spend down to Medicaid. It also supports states’ long-term care rebalancing efforts. 

Since 2008 AoA has worked closely with the Veterans Health Administration to provide an 

additional opportunity to State Units on Aging (SUAs) and Area Agencies on Aging (AAAs) to 

serve veterans of all ages at risk of nursing home placement. 

For additional information about the CLP program go to the AoA website: 

http://www.aoa.gov/AoARoot/AoA Programs/HCLTC/NHD/index.aspx 


Community Living Program – State Projects 

AoA launched the Community Living Program (CLP) initiative in the fall of 2007. In FY2007, 

FY2008, and FY2009, AoA issued awards to12, 14 and16 states respectively to initiate new 

projects or maintain and expand a state’s current projects. In all, 28 states have received 

CLP grants. The total of federal and non-federal funds dedicated to the CLP program in 

FY2009 was almost $12 million, with a cumulative total for all 3 years of $36 million. With the 

implementation of the 2009 CLP grants, there are more than 120 CLP program sites 

nationally. In FY2010, continuation grants were awarded to the 16 FY2009 grantees. 


Program: Community Living Program 

Grant Number: 90CD1199 

Project Title: Alabama's Community Living Program 




770 Washington Avenue, Suite 470 P.O. Box 301851 


Contact: 

Julie Miller 

Tel. (334) 353-9285 

Email: julie.miller@adss.alabama.gov 

AoA Project Officer: Linda J. Velgouse 

Fiscal 

Year 

Funding 

Amounts 









Total $713,684 


The Alabama Dept. of Senior Services (ADSS) in Partnership with South Alabama Regional 

Planning Commission (SARPC) with other stakeholders have as a project goal to implement 

program and infrastructure changes in methods which SUAs and AAAs use to serve and 

manage persons at high risk of Medicaid spend down and nursing home placement that 

improve quality for individuals and help transform Alabama’s long- term care system. 

Objectives: 1) establish a fully functioning aging and disability resource center in SARPC; 2) 

identify individuals at high risk of nursing home placement and Medicaid spend down; 3) develop 

formal policies for “Prioritization” as a method to provide a sustainable community living program 

in Alabama and utilize the DON assessment to target individuals at greatest risk; 4) provide a mix 

of flexible person-centered services with a cash and counseling model based on assessed needs 

and preferences; 5) utilize 20% of grant funds and Title III funds providing person-centered 

services to a minimum of 50 individuals during the 24 month project; 6) ADSS will provide 

direction and oversight for the infrastructure development of brokerage and fee-for-service 

case management, cost sharing, and private pay resources; 7) ADSS will develop protocol 

and guidelines to apply for Veteran’s Department Home and Community-Based Services 

program for SARPC. Outcomes: 1) infrastructure supporting consumer directed programs; 

2) strengthened capacity providing streamlined information and long-term care counseling; 3) 

clients served based on greatest need and risk of spend down and nursing home placement. 




Project Title: Florida Community Living Program Pilot Project 






Contact: 

Jay Breeze 

Tel. No. (850) 414-2338 



Fiscal 

Year 

Funding 

Amounts 









Total $965,430 


The Florida Department of Elder Affairs (FDOEA) Community Living Program (CLP) project 

targets elders at high risk for nursing home placement and spend down to Medicaid. The 

project operates in Broward, Marion and Miami-Dade counties in concert with the Planning 

and Service Area (PSA) 10 Aging and Disability Resource Center (ADRC), and PSAs 3 and 

11 Aging Resource Centers (ARCs), respectively. The goal of the project is to build on the 

current CLP Project and expand innovative service delivery options in the areas served by 

the existing ADRC/ARCs. This expansion will increase the capacity of the aging services 

network and minimize the number of elders placed in nursing homes, readmitted to hospitals, 

or spending down to Medicaid. Project objectives include: 1) creating a self-sustaining 

administrative structure by developing a financial management system that supports 

consumer directed care (CDC) as a long-term alternative to traditional home and communitybased 

services (HCBS); 2) identifying individuals not eligible for Medicaid but at high risk for 

nursing home placement and spend down to Medicaid utilizing and enhancing existing 

ADRC/ARC methods to improve targeting effectiveness in diverting clients; 3) strengthening 

the aging network’s capacity to track client outcomes and document effectiveness of the 

program; and 4) rapidly authorizing and providing services by creating new and flexible 

service options using existing funding streams. The CLP project will emphasize greater 

flexibility in the use of state program funding; rapid authorization of services that offer a 

consumer-direction option; and responsiveness to the unique and changing needs of the 

target population, independent of funding sources. 




Project Title: Expansion of Georgia's Community Living Program to the 

Northwest Georgia Planning and Service Area 




Division of Aging, 9th Floor 

2 Peachtree St., NW 


Contact: 

Kim Grier 

Tel. (404) 520-2101 

Email: kagrier@dhr.ga.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $959,691 


Georgia’s Department of Human Services, Division of Aging Services will implement this 

Community Living Program Project with the Northwest Georgia Area Agency on Aging 

(NWGA AAA) in the fifteen-county Northwest Georgia region. The goal of the project, 

Georgia’s Consumer Support Options (CSO), is to support the rebalancing of Georgia’s longterm 

care system. The objectives are: 1) to divert persons at risk of nursing home placement 

and Medicaid spend down; 2) to use established targeting criteria (established during the 

previous grant cycle) for the intake and screening process through the single-entry point 

Gateway system 3) to initiate the modernization of the Northwest Region’s aging services 

network by reallocating Title III and other non-Medicaid funds to support flexible spending 

pools; 4) to implement the DAS consumer-directed model of care, allowing consumers to 

tailor services to their individual needs; 5) to develop and maintain a Fiscal Management 

Service at the NWGA AAA; and 6) work with the Atlanta Veteran’s Administration Medical 

Center to provide the Veterans Directed Home and Community Based Service (VDHCBS) 

program, and, to implement the TCARE protocol of caregiver assessment for the VDHCBS 

caregivers. Anticipated outcomes are: 1) a significant number of individuals at risk for 

nursing home placement, but not Medicaid eligible, will delay or avoid nursing home 

admission: and 2) veterans will have the opportunity to enroll in a self-directed care program. 

The deliverables are a Flexible Spending Fund Pool to support CSO, a Fiscal Management 

Service Operations Manual, the implementation of a VDHCBS program option, 4) marketing 

and promotional materials, and interim and final reports. 




Project Title: Hawaii's Community Living Project 



Hawaii Executive Office on Aging 



Contact: 

Nancy Moser 

Tel. (808) 586-0185 

Email: nancy.moser@doh.hawaii.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $950,880 


The Hawaii Executive Office on Aging (EOA), which operates the Hawaii Aging and Disability 

Resource Center (ADRC), is conducting the Community Living Program (CLP) in 

collaboration with the Department of Human Services (the state Medicaid agency), State 

Council on Developmental Disabilities, Disability Communication Access Board, Area 

Agencies on Aging, and community service providers. The goal is to assist individuals who 

are not Medicaid eligible, but at imminent risk of nursing home placement, to remain in the 

community, avoiding institutionalization and spend-down to Medicaid. The objectives include: 

1) identifying at-risk individuals through ADRC and link them to home and community-based 

services (HCBS), including consumer directed options, to retain them in community living; 2) 

coordinate ADRC’s intake and assessment protocol with Medicaid level-of-care and eligibility 

tools; 3) identify those at risk of nursing home placement and not Medicaid eligible by adding 

CLP data elements to ADRC assessment protocols; using Financial Management Services to 

activate the option for consumer direction; and, 4) to serve at least 90 individuals. Expected 

outcomes after two years include: 1) 80 individuals will avoid institutionalization and spend 

down to Medicaid; 2) ADRC sites will use a common intake form to assess individuals for 

service needs; and, 3) individuals who need support to remain living in the community have 

the option to elect consumer-directed services. 




Project Title: Building a Community Living Program for the State of Indiana 




Division of Aging 

402 W. Washington St. 


Contact: 

Andrea Vermeulin 

Tel. (317) 234-6572 



Fiscal 

Year 

Funding 

Amounts 









Total $965,652 


The Indiana Family and Social Services Administration (FSSA) is collaborating with the 

state’s Area Agencies on Aging (AAAs) to develop a Community Living Program (CLP). The 

project goals are to establish mechanisms to ensure that individuals at greatest risk of 

nursing facility (NF) placement and Medicaid spend down receive services, and to build 

infrastructure necessary to support the growth of person-centered (PC) and participantdirected 

(PD) supports. The objectives include: 1) pilot and validate a research-based, 

objective, and standardized approach to targeting non-Medicaid funded home and 

community-based services (HCBS) to individuals most at risk of entering a NF and spending 

down to Medicaid eligibility;; 2) incorporate a PC approach into CLP operations; develop a 

data-driven quality management system for the CLP; 3) increase the flexibility of PD options; 

and 4) develop infrastructure that will provide counseling to accompany the PD services 

offered under the CLP. Outcomes include: 1) a successful pilot of the MDS-HC’ 2) the 

adoption of targeting criteria and policies for assigning priority access to high-risk individuals; 

3) a standardized approach for triaging assessments; 4) a process that results in 100% of the 

participants in the pilot sites having a PC experience when applying for and receiving services 

from the CLP; 5) identification of performance indicators (PIs); 6) new and modified data 

collection instruments and protocols, management reports, and remediation policies and 

procedures; 7) support delivery infrastructure that allows individuals to pay for items and a plan 

for expanding PD to other funding streams; a participant manual, forms and other tools, Care 

Coordinator training, and 8) a mentoring program that serves at least 10 individuals. 




Project Title: Maine's Community Living Program 







Augusta, ME 04333-0011 

Contact: 

Romain Turyn 

Tel. (207) 287-9214 



Fiscal 

Year 

Funding 

Amounts 









Total $640,813 


The goals of Maine’s Community Living Program are to: strengthen the capacity of Maine’s 

Aging Network to target individuals not eligible for Medicaid who are at highest risk of nursing 

home or residential care placement and spend-down; improve access to flexible and 

consumer-directed services for participants within 12 months. Objectives include: 1) 

establishing the Area Agencies on Aging/Aging and Disability Resource Centers as Single 

Entry Points for individuals targeted in this proposal; 2) developing/implementing options 

counseling protocols to inform consumer decision-making and spending; 3) developing/using 

an assessment protocol for determining risk; 4) creating more flexibility in Maine’s consumerdirected 

Family Provider Service Option; 5) educating the public, service providers and 

referral sources about the availability of options counseling; and 5) establishing consumer 

monitoring and feedback mechanisms. Outcomes include: 1)increasing private pay 

individuals who access options counseling; 2) increasing consumers well-being and quality of 

life; 3) improving communication and understanding among partner organizations about 

options counseling; 4) Improving AAA/ADRC ability to identify individuals at-risk for nursing 

home admission and spend-down; 5) improving flexibility within the Family Provider Service 

Option Program; 6) diverting at-risk elders from nursing homes and residential care and 

Medicaid spend-down; 7) AAA/ADRC staff trained on and using new protocols; and 8) 

strengthening network of long-term services and supports. 




Project Title: Massachusetts Community Living Program 




One Ashburton Place, 5th Floor 


Contact: 

Ruth Palombo 

Tel. (617) 222-7512 

Email: Ruth.Palombo@state.ma.us 


Fiscal 

Year 

Funding 

Amounts 









Total $959,285 


The Massachusetts Executive Office of Elder Affairs and the Massachusetts Rehabilitation 

Commission is strengthening the capacity of the Aging and Disability Resource Consortia 

(ADRC) network to prevent people from unnecessary nursing home placement through 

implementation of the Community Living Program (CLP) grant. Adults and adults with 

disabilities in the state-funded Enhanced Community Options Program (ECOP) who are at 

greatest risk of nursing home admission will be referred to either Aging Service Access 

Points (ASAPs) or to Independent Living Centers (ILCs) for evaluation and access to home 

based services that include a consumer directed option. The use, cost and effectiveness of 

services in averting nursing home placement will be tracked for all participants. The program 

will build on successful diversion practices at Massachusetts’ eleven ADRCs and address 

opportunities to develop their capacity to: 1) provide ECOP, information on consumer 

direction, and referral to community-based services; 2) use their information and referral 

services and field-based staff to identify the target population; 3) track ECOP’s effectiveness 

in nursing home diversion; 4) reach out to hospital, nursing and rehabilitation facility 

discharge staff to improve relationships; and 5)identify service gaps that may contribute to 

nursing facility admission. In addition, the program will increase capacity of ASAPs, who are 

key partners within the ADRCs, to offer ECOP consumers the opportunity to direct their own 

services, using individual budgeting. 




Project Title: Minnesota's Community Living Program 2009 - 2011 



Minnesota Board On Aging 


PO Box 64976 

St. Paul, 55164-0976 

Contact: 

Jane Vujovich 

Tel. (651) 431-2573 

Email: jane.vujovich@state.mn.us 


Fiscal 

Year 

Funding 

Amounts 









Total $959,286 


The vision for Minnesota’s Community Living Program (MCLP) grant project is to reduce 

Medical Assistance (MA) spending by supporting pre-Medical Assistance (MA) high-risk older 

adults in self-managing their risk factors and maximizing their use of flexible service options. 

Minnesota’s Live Well at Home Program (LWAHP) (i.e., Nursing Home Diversion Program 

2007-2009) strategically identifies and helps high-risk persons proactively manage risk 

factors. The goals of MCLP are to: 1) bolster the Aging Network’s capacity to target pre-MA 

eligible high-risk older adults and family caregivers through statewide implementation of the 

LWAHP; 2) broaden statewide capacity to offer self-directed support options to at-risk 

persons; 3) establish a system-wide approach to measure and report target group diversion 

from MA. Minnesota will partner with all Area Agencies on Aging (AAAs) to achieve the 

following objectives: 1) broadly disseminate the Rapid Screen tool; 2) integrate diversion 

support services and risk management protocols into the MinnesotaHelp Network; 3) build 

capacity and sustainability for high quality diversion support services; and 4) implement 

Veterans-Directed Home and Community-Based Services Option. The expected outcomes 

are: 1) Increased number of persons using the Rapid Screen, taking action to manage their 

risks; and buying self-directed support; and, 2) Ultimately, evidence of MA savings. Core 

products are risk management materials; consumer materials; a final report with evaluation 

results; an enhanced web-portal; and provider standards and training program. 




Project Title: Community Living Program 



Montana Department of Public Health and Human Services 

Senior and Long Term Care 

111 Sanders 

P O Box 4210 

Helena, MT 59604 

Contact: 

Charles Rehbein 

Tel. No. (406) 444-7743 

Email: crehbein@mt.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $845,754 


The goal of Montana’s Community Living Program is to support the rebalancing of Montana’s 

long-term care system by assisting individuals, and their family and informal caregivers, who 

are at imminent risk of nursing home placement and not eligible for Medicaid, to use home 

and community based services to remain at home and in the community, and thus avoiding 

unnecessary nursing home placement. Major objectives are to: 1) expand ADRC model to 

one additional county in Area XI (Ravalli County); 2) design and implement targeting and 

assessment protocols to identify non-Medicaid older adults at imminent risk of nursing home 

placement and Medicaid spend-down; 3) develop a consumer directed option for Older 

Americans Act (OAA) funded services based on the Big Sky Bonanza program, allowing 

flexible spending options; and 4) maximize the number of persons served with OAA funds by 

introducing cost sharing for appropriate in-home services. The expected outcomes are: 1) 

serving at least 50 individuals who are identified at imminent risk of nursing home placement 

and Medicaid spend-down; 2) establishing a process to identify and target at-risk clients and 

offer them consumer directed services; 3) providing consumer direction for in-home services; 

4) strengthening the capacity to provide information and services to help individuals remain in 

the community; and 5) expanding the cost sharing model to additional in-home services. The 

products of this project are a final report including evaluation results; data on consumers 

served by the project; and new policies, protocols and tools that support consumer directed 

services for seniors. 




Project Title: Statewide Expansion of the Consumer Transitions in Caring Model 




Bureau of Elderly and Adult Services 

129 Pleasant Street 

Concord, NH 03301 

Contact: 

Kathleen F. Otte 

Tel. (603) 271-4680 

Email: Kathleen.F.Otte@dhhs.state.nh.us 


Fiscal 

Year 

Funding 

Amounts 









Total $929,316 


The New Hampshire Bureau of Elderly and Adult Services (BEAS), in partnership with the 

Institute on Disability at UNH (IOD), proposes to actualize the transformation of caregiver 

support services in New Hampshire, by expanding the Transitions in Caregiving Program 

statewide. Transitions in Caregiving (TIC) is a consumer-directed model that supports 

informal caregivers caring for older adults at risk of placement in a nursing facility and 

ultimately spend down to Medicaid. TIC is currently being implemented in 7 regions of the 

state through the ServiceLink Aging and Disability Resource Centers (SLRC’s) utilizing 

funding from previous NHDM grants and a Weinberg Foundation grant. The goal of this 

proposal is to actualize the transformation of the caregiver support program from a 

centralized, state-managed model into a flexible, consumer-directed model managed at the 

local level through the SLRC’s and implement it statewide. Objectives include: 1) expand the 

infrastructure established under the initial NHDM project statewide; 2) provide a 

comprehensive array of supports to family caregivers and train professional staff in the 

consumer directed model; 3) pilot the model in one region with veterans at risk of nursing 

home placement; 4) educate legislators and submit legislation to sustain the TIC program; 

and 5) evaluate the efficacy of the program. Outcomes include: 1) statewide implementation 

with secured funding; and 2) services to veterans, under the Veteran’s Directed Home and 

Community-Based Care Services. 




Project Title: New York State: Community Living Program 




Policy Research and Legislation 


Albany, NY 12223-1251 

Contact: 

Gail Koser 

Tel. (518) 474-4425 



Fiscal 

Year 

Funding 

Amounts 









Total $959,284 


New York State Office for the Aging, with its partners, will develop a peer mentoring learning 

community to expand and enhance self-directed capacity for nursing home diversion in aging 

network and VA consumers. The goal of the project is to build statewide capacity to offer 

seamless, flexible service delivery including self-directed options to divert participants from 

nursing home placement and Medicaid spend-down. This project builds upon work begun 

with Broome, Oneida and Onondaga AAAs, expands to 7 additional AAAs, serves over 200 

persons (19% of eligible’s in those counties) at imminent risk for nursing home placement 

and Medicaid spend-down and prepares for statewide adoption of flexible service delivery 

including self-directed approaches. Objectives include: 1) expand self-directed program 

capacity to serve 200 consumers in 7 AAAs; 2) build the foundation to expand to 25% of 

State’s AAAs; 3) implement continuous quality improvement strategies; 4) set-aside Federal 

and State monies to support self-directed approaches to targeted populations; and 5) amend 

Expanded In-Home Services for the Elderly program regulations to support self-directed 

delivery and implementation in 25% of State’s AAAs. Outcomes include: 1) diversion of 

persons at-risk for nursing home placement and Medicaid spend-down; 2) funding 

realignment; 3) increased quality delivery; and, 4) statewide replication/sustainability. 

Products will include a final report with evaluation results, policy, procedures, and toolkit 

dissemination. 




Project Title: Oregon Community Living Project 







Contact: 

Elaine Young 

Tel. (503) 373-1726 



Fiscal 

Year 

Funding 

Amounts 









Total $667,488 


The State of Oregon Department of Human Services, Seniors and People with Disabilities 

Division (SPD), in collaboration with two Area Agencies on Aging - Multnomah County Aging 

and Disability Services (ADSD) and Washington County Disability, Aging, and Veterans 

Services (DAVS) – is conducting a Community Living Program grant funding to enhance 

efforts at diverting individuals from nursing home placement and empowering them to be 

well-informed long-term care consumers. The goal of this project is to pilot key systemic 

changes at ADSD and DAVS that will enable those at risk of nursing facility placement and 

spend-down to Medicaid to remain in home and community-based settings. Project 

objectives include: 1) revising the intake screening process to identify and respond quickly to 

those at imminent risk; 2) implementing long-term care options counseling to help targeted 

individuals and their families make informed decisions about available services; 3) expanding 

existing programs that promote self-directed care and developing new Web-based tools that 

enable consumers to research benefits and service options; 4) increasing knowledge, skills, 

and abilities of case management staff and community partners to equip them to provide 

consumer-directed care; and, 5) developing an evaluation process to track client outcomes 

and cost avoidance attributable to nursing facility diversion activities. Outcomes are: 1) key 

indicators of imminent risk will be validated; 2) consumer awareness and use of home and 

community-based services will increase as a result of long-term care options counseling; 3) 

100 at-risk individuals will delay or avoid nursing home placement and spend-down to 

Medicaid; and 4) screening and case management staff will increase their knowledge, skills, 

and abilities to provide consumer-directed care. 




Project Title: Home and Community Based Services for Seniors, Adults with 

Disabilities and Veterans 







Contact: 


Tel. No. (803) 734-9939 


AoA Project Officer: Linda J. Velgourse 

Fiscal 

Year 

Funding 

Amounts 









Total $724,161 


The South Carolina Lieutenant Governor’s Office on Aging’s (LGOA) Community Living 

Program: Supporting Independence and Choice in the Community, is being developed in 

collaboration with the VA Medical Center in Charleston (the Ralph H. Johnson VA Medical 

Center), the Trident Aging and Disability Resource Center. The goal of the program is to 

improve access to information and services, and increase options and consumer direction for 

non-Medicaid eligible Veterans/seniors who need nursing home level of care but who choose 

to remain in the community. Objectives include: 1) development of a consumer directed 

Community Living Program through a unified coordination of care concept to ensure 

recognition of, and satisfaction with, individual preferences for community based services; 2) 

identification and recruitment of service providers to assist the Veteran/senior; 3) and 

development of enhancements to existing systems that promote information sharing across 

previously existing “silos.” Additional objectives include: 1) improvement of home and 

community based services for Veterans/seniors needing nursing home level of care by 

coordinating training and education for the Veteran/senior, family members, caregivers and 

ancillary participants; and 2) utilization of information system enhancements to facilitate wellinformed 

consumer directed service plans as early as possible. Expected outcomes include: 

1) increased access to services and information; 2) increased consumer control; 3) increased 

independence through community based services; and 4) greater likelihood of delayed 

relocation to a facility. Products will include a summary of lessons learned, a manual that will 

allow others to implement the demonstrated program, and a cost analysis providing an 

estimate of the cost of program start-up and operation. 




Project Title: Community Living Program of Tarrant County 




701 W. 51st Street 


Contact: 

Winnie Rutledge 

Tel. No. (412) 438-5891 

Email: winnie.rutledge@dads.state.tx.us 


Fiscal 

Year 

Funding 

Amounts 









Total $924,683 


Texas Department of Aging and Disability Services, collaborating with the Area Agency on 

Aging of Tarrant County (AAATC) and the ADRC of Tarrant County (ADRCTC), are 

developing a Community Living Program (CLP) for caregivers and older persons at imminent 

risk of nursing home placement and Medicaid spend down. Goals are to: 1) refine, expand 

and replicate CLP in a densely populated urban area, and 2) expand the scope and array of 

consumer-directed and evidence-based services to maximize consumer choice. The ADRC 

will refine screening of at-risk consumers and provide intensive in-home services using 

agency-based and consumer directed services to delay nursing home placement. The 

objectives are: 1) effectively target consumers, including veterans, with needed community 

services and supports; 2) refine income screening, cost sharing and flexible Older Americans 

Act (OAA) funds to delay Medicaid spend down; 3) reduce time from first call to service 

initiation; 4) expand agency-based and voucher options to purchase services; 5) integrate 

person-centered evidence-based programs into service navigation functions; and 6) improve 

accountability of in-home service providers. The expected outcomes are: 1) blueprint for 

transformation of ADRC and AAA networks for more targeted allocations of resources and 

expanded arrays of consumer directed services to maintain consumers in the community and 

provide caregiver support; and 2) attaining targets of 80% of consumers living in the 

community six months after services begin and 70% at 9 months. The major products from 

this project are: final evaluation results, including analysis of consumer satisfaction and 

success of integrating evidence based practices into service navigation functions; and statelevel 

policy changes pertaining to flexible use of OAA funds. 




Project Title: Community Living Program: Choices for Independence 



Virginia Department on Aging 



Contact: 

Katy Miller 

Tel. No. (804) 662-7035 

Email: kathy.miller@vda.virginia.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $939,730 


The Virginia Department for the Aging (VDA), in partnership with ten Area Agencies on Aging 

(AAA), proposes to significantly enhance the modernization of Virginia’s system of long term 

care for seniors and veterans by expanding the Community Living Program (CLP) to over half 

of the Commonwealth. Project objectives include: 1) diverting individuals at imminent risk of 

nursing home placement and spend-down to Medicaid; 2) providing consumer directed 

options and a flexible array of community services to meet participant’s individual needs; and 

3) embedding a sustainable CLP model of service delivery into Virginia’s network of aging 

services by building on the foundation established in Virginia’s 2008 CLP initiative and 

significantly expanding the program in both size and reach. Outcomes include: 1) 100 

eligible seniors diverted from nursing home placement and spend-down to Medicaid; 2) 8 

additional AAAs implementing CLP programs and offering consumer direction of services to 

both seniors and veterans; 3) 65 Service Coordinators trained in all aspects of CLP; 4) fiscal 

practices redesigned to allow flexible funding of an array of services from a choice of 

providers; 5) demonstration of the efficacy of telemedicine to help rural seniors remain safely 

in their homes; 6) improved speed and efficiency of client assessment and service initiation 

through Virtual Intake Centers; 7) continued refinement and documentation of Virginia’s CLP 

model; 8) comprehensive client and service tracking through specialized software; and 9) 

evaluation of the CLP to document success in delaying or avoiding nursing home placement, 

cost effectiveness of the program and client satisfaction. 




Project Title: Wisconsin Community Living Program 




Division of Long Term Care 


Madison, WI 53707-7850 

Contact: 

Wendy Fearnside 

Tel. No. (608) 266-5456 

Email: wendy.fearnside@wisconsin.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $937,796 


The Wisconsin Department of Health Services is developing a Community Living Program 

(CLP) in partnership with the Greater Wisconsin Agency on Aging Resources and the Aging 

and Disability Resource Center (ADRC) of Kenosha County and a Veteran Directed Home 

and Community Based Services program, in cooperation with the Milwaukee VA Medical 

Center. The goal of Wisconsin’s CLP program is to develop the capacity of the State’s aging 

network to help people who are not eligible for Medicaid to avoid unnecessary or premature 

nursing home placement and impoverishment. Objectives are: 1) to develop and pilot a CLP 

model that facilitates use of personal resources supplemented with public funding to secure 

individually-tailored services to help people through situations that put them at immediate risk 

of nursing home admission; and 2) to better understand the situations that lead to private pay 

nursing home admissions and spend down, the impact of options counseling and care 

management on admissions decisions, the types of services that will effectively help people 

avoid institutionalization and spend down; and the cost of providing those services. The 

expected outcomes are: 1) at risk individuals will live at home longer and maintain maximum 

control over their lives; and 2) the State will have documentation to support future policy and 

funding decisions regarding use of ADRC, Older Americans Act and other funding. The 

products will include tools and protocols for identifying at risk individuals, assessing needs, 

prioritizing and authorizing services, accessing public funding for services, and facilitating self 

direction; client-specific outcome data; and a detailed evaluation report. 


Community Living Program – Consumer Direction Technical Support 

The concept of consumer direction in delivery of home and community long-term care 

services was first explored by the Robert Wood Johnson Foundation (RWJF) program, 

Independent Choices: Enhancing Consumer Direction for People with Disabilities, which 

supported State demonstrations from 1995 to 1999 and stimulated the expansion of this 

concept to the field of aging. In 1998 The Robert Wood Johnson Foundation (RWJF), the 

Office of the Assistant Secretary for Planning and Evaluation in the United States Department 

of Health and Human Services (ASPE/DHHS), and the Administration on Aging (AoA) 

supported three States in demonstrations incorporating consumer direction by giving persons 

living at home who needed services to remain independent money to purchase those 

services. The Case and Counseling Program supported a National Program Office located at 

the Boston College Graduate School of Social Work, now known as the National Resource 

Center for Participant-Directed Services (NRCPDS), to provide assistance in implementation 

of the demonstrations and the comparison of the Cash and Counseling consumer-directed 

model with the traditional agency-directed approach to delivering personal assistance 

services. 

In FY2008, AoA awarded a grant to Boston College and its NRCPDS to provide technical 

assistance to its Community Living Program grants where consumer direction is a core 

concept. 


Program: Community Living Program – Technical Support Project 

Grant Number: 90OP0002 

Project Title: Technical Support for Consumer-Directed Programs 



Boston College 

Graduate School of Social Work 

140 Commonwealth Avenue 

Chestnut Hill, MA 02467 

Contact: 

Kevin Mahoney 

Tel. (617) 552-4039 

Email: Kevin.mahoney@bc.edu 


Fiscal 

Year 

Funding 

Amounts 









Total $998,888 


The grantee, the National Center for Consumer Direction (NCCD) at the Boston College 

Graduate School of Social Work, supports the goals enunciated in the Older Americans Act 

Amendments of 2006 and will provide valuable assistance to the Aging Network as it works to 

increase choices and consumer-directed options for high risk individuals that help to keep 

them in their homes and communities. The goal of the project is to help states and Area 

Agencies on Aging increase the consumer direction options available to their constituents. 

The objectives are: 1) to help programs identify consumer direction status, technical 

assistance needs and plans in their areas; 2) to provide states and Area Agencies on Aging 

with opportunities to participate in regular training sessions to increase their knowledge about 

and ability to provide consumer directed/flexible service options; 3) to identify leaders, both 

consumers and professionals, to help advance the development of consumer directed 

options; and 4) to develop linkages with and among Area Agencies on Aging and other 

programs working in the areas of consumer direction. The expected outcomes of this project 

are: 1) that at least ten programs will develop basic support structures for consumer directed 

programming; 2) at least eight programs will increase the degree to which consumer-directed 

options are available; and 3) a network of consumer directed champions will be developed to 

advocate for and assist in the development of consumer direction. The products from this 

project will include: educational materials, including webinars and content for use at national 

conferences; a minimum of three Promising Practice Reports; and core performance 

indicators for consumer direction specific to the Aging Network. 


Evidence-Based Disease and Disability Prevention Program 

In 2003, AoA began funding pilot programs to test the translation of the Evidence-Based 

Disease and Disability Prevention programs in the Aging Services Network’s communitybased 

settings. Based on the positive results from these pilot programs, AoA increased its 

Federal support of the Evidence Based and Disease and Disability Prevention Program in 

2006 by initiating its state-based Evidence-Based Disease and Disability Prevention Program 

(EBDDP) program for seniors, in collaboration with the Centers for Disease Control and 

Prevention (CDC), the Agency for Healthcare Research and Quality (AHRQ), the Centers for 

Medicare and Medicaid Services (CMS) and a variety of private foundations. Through public 

and private partnerships, States have provided evidence-based programs to older adults in 

their communities. 

AoA requires each participating state to implement the Stanford University Chronic Disease 

Self-management Program (CDSMP), but also gives each state the option to select another 

program which helps reduce chronic disease in its senior population. These programs may 

include: Physical activity, falls management, nutrition and depression and/or substance 

abuse programs, 

More information about EBDDP may be found on the AoA website: 

http://www.aoa.gov/AoARoot/AoA Programs/HPW/Evidence Based/index.aspx 


Evidence-Based Disease Prevention – State Programs 

The Administration on Aging (AoA) initiated this program with a FY2006 funding opportunity 

announcement entitled: ”Empowering Older People to Take More Control of their Health 

Through Evidence-Based Prevention Programs: A Public/Private Collaboration.” The 

concept was initiated in part to support and complement emerging emphasis on prevention 

and chronic disease management in Medicare. As indicated in its title, the new grants were 

designed to mobilize the aging, public health and non-profit networks at the State and local 

level to accelerate the translation of HHS funded research into practice through the 

deployment of low-cost evidence-based disease and disability prevention programs at the 

community level. The expected long term benefit of this investment was to improve the 

quality of life of our seniors and reduce the cost of health care over the long run. 

The 25 projects funded in FY2006 received continuation support in FY2010 for their final 5 th 

year. Since their initiation new Medicare benefits have been authorized which support 

preventive care for seniors and reinforce the need for evidence based programming for both 

evidence-based prevention programs as well as Chronic Disease Self Management 

Programs (CDSMP) to enhance the qualify of life for seniors. The American Recovery and 

Reinvestment Act of 2009 included provisions allowing AoA to support new CDSMP 

programs in States and continue its efforts to develop both infrastructure and support for 

evidence-based program at the community level. The CDSMP initiative is described 

elsewhere in this compendium (See Chronic Disease Self-Management Program) 

For more information about the Evidence Based Prevention Program go to the AoA website: 



Program: Evidence Based Disease Prevention – State Programs 

Grant Number: 90AM3134 

Project Title: Arizona On The Move For Healthy Aging 



Arizona Department of Health Services 

Public Health Prevention Services 

150 North 18th Avenue Suite 520 


Contact: 

Ramona L. Rusinak 

Tel. No. (602) 364-0526 

Email: rusinar@azdhs.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $825,000 


The Arizona Department of Health Services and its partner the Arizona Department of 

Economic Security, Division of Aging and Adult Services (ADES-DAAS) through the Arizona 

on the Move for Healthy Aging Project are implementing the Chronic Disease Self- 

Management Program (CDSMP) and Enhance Fitness (EF) programs in Pima, Santa Cruz 

and Yavapai counties over four years. The goals are to: 1) implement evidence-based 

prevention programs targeting adults 60+; and 2) build and strengthen state and local healthy 

aging partnerships focused on prevention services targeting older adults. The objectives are: 

1) to develop a resource of CDSMP and EF trainers at the state and local levels, 2) establish 

CDSMP and EF programs in three counties; and 3) integrate evidence-based prevention 

programs into planning and policy in state public health and aging networks. The outcomes 

of this project will be increased training and prevention program resources in two rural and 

one urban county, along with strong partnerships at local and state levels to increase 

capacity and infrastructure for prevention services targeting adults 60 years and older. An 

additional outcome will be the availability of data demonstrating the benefit to adults 60 years 

and older of participation in chronic disease self-management programs. The products from 

this project will include a final report, evaluation results from the courses, data on health 

status and outcomes of participants to be used in fact sheets for policy and decision-makers, 

abstracts for national aging and public health conferences, and project information and 

resources available on the Healthy Aging Communication Network website and through the 

Arizona Aging and Disability Resource Center. 




Project Title: Arkansas Empowering Older Adults Project 



Arkansas Department of Health 

P.O. Box 1437, H- 41 

Little Rock, AR 72204-1437 

Contact: 

Becky Adams 

Tel. No. (501) 661-2334 

Email: becky.adams2@arkansas.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $825,000 


The Arkansas Department of Health is initiating the Arkansas Empowering Older Adults 

Project. The DOH has the following partners: the Department of Human Services, Division 

of Aging and Adult Services (DAAS), the University of Arkansas for Medical Sciences 

Reynolds Institute on Aging - Arkansas Aging Initiative, Area Agencies on Aging, the Aging 

and Disability Resource Center, aging service providers in each region, and local Hometown 

Health Improvement coalitions. The goal is to empower older Arkansans to take greater 

control of their health through lifestyle changes and to reduce their risk for chronic diseases 

and disability by delivering evidence-based prevention programs. The two proposed 

programs to be implemented are the Stanford Chronic Disease Self-Management Program in 

two regions and the Active Living Every Day, physical activity program statewide. The 

objectives are to: 1) develop program infrastructure; 2) train facilitators and master trainers; 

3) implement the programs; 4) provide opportunities for physical activity for older adults; 5) 

maintain fidelity to the original design; 6) assess the impact of programs; and 7) disseminate 

project information. The expected outcomes are for participants to demonstrate positive 

lifestyle changes; increase their ability to cope with challenges and barriers to exercise; 

decrease chronic disease risk factors; and successfully collaborate and mobilize project 

partnerships. 




Project Title: Initiative to Empower Older Adults to Better Manage Their Health 



California Department on Aging 

1300 National Drive, Suite 200 


Contact: 

Janet Tedesco 

Tel. No. (916) 928-4641 

Email: jtedesco@aging.ca.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $1,050,000 


The California State Departments of Aging and Health Services, local AAAs, public health 

and non-profits throughout the state, are proposing to implement the Stanford Chronic 

Disease Self-Management Program (CDSMP) and/or Matter of Balance (MOB), a fall 

prevention program in five geographic areas and in several Multipurpose Senior Services 

Programs, introducing Medication Management and Healthy Moves. The goal is to create an 

effective infrastructure that includes both state and local partnerships to implement 

sustainable evidence-based prevention programs for older people within the state's aging 

network. The objectives are to: implement the CDSMP and/or MOB in geographic areas that 

represent 40% of the state's seniors; disseminate two additional evidence-based programs 

for frail, dually eligible seniors in at least six communities; and provide technical assistance to 

the identified local partnerships as prototypes for further expansion. The anticipated 

outcomes are to create a sustainable network to provide community education and evidencebased 

programs for diverse older adults; integrate evidence-based programs into at least five 

geographic regions; and conduct outreach that will successfully recruit approximately 6,000 

high risk seniors to the initiative. 




Project Title: Empowering Older People to Take More Control of Their Health: 

Evidence-Based Prevention 



Colorado Department of Health and Environment 

Preventive Services Division 

PSD-COPAN-A5 

4300 Cherry Creek Drive South 


Contact: 

Michelle Hansen, MS, RD, CDE 

Tel. No. (303) 692-2577 

Email: Mmhansen@smtpgate.dphe.state.co.us 


Fiscal 

Year 

Funding 

Amounts 









Total $1,000,000 


The Colorado State Unit on Aging (SUA) and the Department of Public Health and 

Environment (CDPHE) support this Healthy Aging Partnership Project in collaboration with 

the Consortium for Older Adult Wellness (COAW). The goal is to expand the existing 

infrastructure of the partnership of the SUA, CDPHE, and COAW to implement and sustain 

the delivery of evidence-based (EB) prevention programs through community aging service 

providers. The objectives are to: 1) create a sustainable delivery system for EB program 

training and implementation, coordination, technical support and fidelity oversight of the 

Chronic Disease Self- Management Program (CDSMP) and A Matter of Balance (MOB) in 

Colorado; 2) modify significant factors caused by chronic diseases or conditions in a 

minimum of 68% of participants; 3) expand the communication network of OAA communitybased 

service providers that encourages the sharing of resources and increases the 

opportunity for collaboration; and 4) make this expanded system sustainable. Expected 

outcomes are: 1) expanded accessibility for older adults to the CDSMP and other evidencebased 

programs (EBP); 2) embed EBP service system into regional health service providers 

that collaborate with regional communities for training, networking, and resource sharing; 3) 

ten trained certified, regional, Master trainers in CDSMP and 50 paired community leaders 

per year; 4) reach 3,500 participants in CDSMP/Matter of Balance; 5) obtain Area Agency on 

Aging support to sustain EB programs by using Title III-D funds/private funding; 6) analyze 

data for evaluation on health indicators, participant reach, and program satisfaction through 

evidence-based disease prevention software; and 7) expansion of existing networks with 

additional EB self-management interventions in physical activity, nutrition, and fall prevention. 




Project Title: Empowering Older People to Take Control of Their Health 







Contact: 

Pamela Giannini 

Tel. No. (860) 424-5277 

Email: pamela.giannini@ct.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $825,000 


The State of Connecticut Department of Social Services and the Department of Public Health 

is developing a collaborative and integrated network of state and local aging, health and nonprofit 

organizations with the goal of empowering older people to take more control over their 

own health through lifestyle changes that have proven effective in reducing the risk of 

disease and disability. Its approach is to translate research evidence into programs at the 

community level by imbedding low-cost prevention programs within existing state and local 

programs. The objectives are to expand these efforts by: 1) developing and enhancing 

linkages across state and local aging, health, and nonprofit organizations; 2) augmenting 

uptake of prevention efforts by training professionals and older adults in the Chronic Disease 

Self-Management Program (CDSMP); 3) training community-based professionals and seniors 

in fall prevention; 4) progressively implementing CDSMP in the designated geographic area; 

5) progressively implementing a fall prevention program in the designated geographic areas; 

6) conducting an impact evaluation; and 7) disseminating the results to Connecticut and to 

other states. Key organizations include three AAAs, University of Connecticut, Yale 

University, and several local health, aging, and nonprofit organizations with Title III funding. 

The expected outcomes include increased knowledge and modified behaviors among 

professionals and seniors concerning chronic disease self-management and fall prevention. 




Project Title: Evidence-Based Prevention Program 




4040 Esplanade Way 


Contact: 

Michele Mule 

Tel. No. (850) 414-2307 

Email: mulem@elderaffairs.org 


Fiscal 

Year 

Funding 

Amounts 









Total $941,690 


The Florida Department of Health, in collaboration with the Florida Department of Elder 

Affairs, supports a three year project entitled "Empowering Older People to Take More 

Control of Their Health through Evidence-Based Prevention Programs". The goal of the 

project is to provide evidence-based interventions for arthritis and other chronic conditions to 

the maximum number of people age 60 years and older that are at risk and can benefit from 

the interventions. The objectives are: 1) to conduct master trainer and leader trainings for 

the Chronic Disease Self-Management Program (CDSMP) in three counties within three 

Planning Service Areas (PSA); 2) to conduct leader training for the Spanish Arthritis Self- 

Management Program (SASMP) in Miami-Dade and Palm Beach counties; 3) to conduct 

CDSMP and SASMP classes; 4) to evaluate the course through pre/post-tests and 

satisfaction surveys; 5) to ensure the fidelity of the implementation of the courses through 

direct observation of the classes and leader checklists; and 6) to disseminate project results. 

The expected outcomes of this project are: 1) for the CDSMP, positive changes in health 

care utilization, social/role activities limitations, disability, energy/fatigue, self-rated health, 

exercise behaviors, cognitive symptom management, communication with physicians, and 

health distress; and 2) for the SASMP, positive changes in self-efficacy, health care 

utilization, depression, disability, pain, energy/fatigue, self-rated health, exercise, cognitive 

symptom management, and use of mental stress management/relaxation techniques. The 

intended products from this project are interim reports, a final report (including evaluation 

results), and abstracts for national conferences. 




Project Title: Healthy Aging Partnership - Empowering Elders (HAP-EE) 



Hawaii Department of Health 


No. 1 Capitol District 

250 S. Hotel Street, Suite 406 

Honolulu, HI 96813-2831 

Contact: 


Phone: (808) 586-0100 



Fiscal 

Year 

Funding 

Amounts 









Total $1,050,000 


Hawaii's Executive Office on Aging (EOA), in partnership with the Department of Health, 

three of Hawaii's four AAAs (Honolulu's Elderly Affairs Division, Hawaii County Office of 

Aging, Kauai's Agency on Elderly Affairs), and OAA-funded service providers and health and 

research partners in each of these three counties, are implementing a Healthy Aging 

Partnership-Empowering Elders (HAP-EE) initiative. This project builds on Hawaii`s Healthy 

Aging Partnership (HAP), a broad partnership established in 2003 to improve older adult 

health by building aging network capacity to implement evidence-based (EB) prevention 

programs in Hawaii's multi-ethnic environment. For 2010-2011 funding period, EOA’s 

objectives are to 1) preserve and leverage the current EnhanceFitness infrastructure to 

expand Hawaii’s Aging Network capacity to deliver evidence-based programming; and 2) to 

deliver high quality EnhanceFitness programs with fidelity, to at-risk older adults. These 

goals support Hawaii State Plan on Aging Goal 3: older adults are active, healthy, and 

socially engaged. Our current statewide projected outcomes are to: 1) establish two new 

sites in the City and County of Honolulu on the island of Oahu; 2) train six new instructors; 

and 3) impact the lives of at least 128 older adults who have not participated in the programs 

previously. 




Project Title: Idaho Lifestyle Interventions for the Elderly 



Idaho Department of Health and Welfare 

Division of Health 

450 West State Street, 6th Floor 

PO Box 83720 

Boise, ID 83729-0036 

Contact: 

Jaime (Hineman) Harding 

Tel. No. (208) 334-5788 

Email: hardingj@dhw.idaho.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $825,000 


The Idaho Department of Health and Welfare, in collaboration with the Idaho Commission on 

Aging, Area Agencies on Aging, and senior centers in Idaho, are implementing health 

promotion programs for seniors on chronic disease self-management and nutrition education. 

The goal is to provide comprehensive programs in three health districts by incorporating 

evidence-based programs into an existing infrastructure that has successfully delivered 

physical activity/fall prevention classes for older people in rural and resource-poor areas. 

The objectives are to: 1) provide a Chronic Disease Self-Management Program (CDSMP); 2) 

contract with senior centers that are hosting other programs to add the CDSMP in their site 

and in other sites in their communities; and 3) train peer leaders for the Healthy Eating for 

Successful Living in Older Adults (HE) program. The outcomes will include: 1) CDSMP 

offered at nine senior centers in three local public health districts; 2) HE program introduced; 

3) enhanced quality of life and greater control over health outcomes experienced by CDSMP 

participants; and 4) improved nutritional status of HE participants. 




Project Title: Empowering Older People to Take More Control of Their Health 



Illinois Department of Public Health 

Office of Health Promotion 

535 West Jefferson 


Contact: 

Thomas J. Schafer 

Tel. No. (217) 782-3300 

Email: tom.schafer@illinois.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $1,000,000 


The Illinois Department of Public Health, in partnership with the Department on Aging, is 

implementing evidence-based disease prevention programs for older adults. The goal is to 

provide the Chronic Disease Self-Management Program (CDSMP) and the Strong for Life 

(SFL) exercise program to persons over age 60 through community-level, not-for-profit aging 

services provider organizations. The objectives are: 1) to begin implementing the CDSMP in 

three, and the SFL program in one, Planning and Service Area (PSA) as defined by the Older 

Americans Act, through AAAs; 2) to begin developing the infrastructure and partnerships 

necessary to effectively embed these programs for the elderly within statewide systems of 

health and long-term care; 3) to promote and refer to clinical preventive services through 

these programs; 4) to evaluate the efforts and monitor the fidelity of each program; and 5) to 

disseminate the results and findings. The expected long-term outcomes will be: potential 

improvement in the quality of life for older people; reduction of older people's risk of disease, 

disability and injury; positive lifestyle and behavioral changes for older persons; reduction in 

the use and cost of health care over time; and the increased availability and accessibility of 

evidence-based programs at the community-level for older persons. 




Project Title: Iowa Healthy LINKS 




Jessie Parker Bldg. Suite 2 

510 East 12th Street 


Contact: 

Kay Corriere 

Tel. No. (515) 725-3330 

Email: kay.corriere@iowa.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $1,050,000 


The Iowa Department on Aging (DOA) and Department of Public Health (IDPH) have 

partnered with three Planning Service Areas (PSAs) - Aging Resources of Central Iowa, 

Heritage Area Agency on Aging and Hawkeye Valley Area Agency on Aging to implement the 

Stanford Chronic Disease Self-Management Program (CDSMP) and Enhance Fitness. The 

initiative is be called the Iowa Healthy Links and its goal is improving the health of older 

Iowans with chronic diseases and increasing Iowa's capacity to provide evidence-based 

health promotion programs for older adults. All three areas are participating in program 

evaluation, creating the benchmarks and measuring the changes in participant's quality of 

life, health care utilization, chronic disease self-efficacy, fruit and vegetable consumption, 

physical activity and strength, along with program sustainability, dispersion, and capacity 

building. The Des Moines University is coordinating program evaluation. Anticipated 

outcomes include: 1) improvement in quality of life measures and health behaviors; and 2) a 

reduction in health care utilization, which will facilitate system development for sustainability. 

Results from the evaluation will be provided to the Iowa Department of Human Services 

(state Medicaid agency), Senior Living Coordinating Unit, State Board of Health, State 

Legislature and private organizations to impact polices and obtain funding for sustaining 

evidence-based preventive programs. The Iowa Healthy Links will provide a model for 

implementing evidence-based health promotion programs in other PSA's with other 

community partners. 




Project Title: Empowering Older Mainers to Take More Control of Their Health 






Augusta, ME 04333 

Contact: 

Diana Scully 

Tel. No. (207) 287-9204 

Email: diana.scully@maine.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $1,050,000 


The Office of Elder Services (Maine's State Unit on Aging) in partnership with the Maine 

Center of Disease Control and Prevention (the State Health Agency known as the Maine 

CDCP) is conducting this project with the goal: to empower older people to take more control 

of their health and reduce their risk of disease and disability. Objectives are: 1) expand 

access to and delivery of five evidence-based prevention programs; 2) expand and develop a 

network of volunteers trained to deliver evidence-based programs; and 3) gain understanding 

of statewide system of communication and referral patterns between health care providers, 

community service organizations, Aging and Disability Resource Centers (ADRCs) and the 

aging and long-term care system in Maine with regard to proposed evidence based 

programs. The target population is older people with chronic conditions, who could improve 

their health through participation in these programs. Significant Partners include the Maine 

CDCP, Area Agencies on Aging, Maine Health's Partnership for Healthy Aging, Aging and 

Disability Resource Centers, and community organizations already participating in evidencebased 

wellness programs. Activities being conducting include: 1) cross-training of existing 

Matter of Balance/Voluntary Lay Leader coaches to administer the Chronic Disease Self- 

Management Program and develop a network of sites at which both programs are co-located 

and available; and 2) expansion of Enhance Fitness and Enhance Wellness programs at 

pilot sites. Outcomes include: 1) increase number of older Mainers who make healthy 

lifestyle changes; 2) development of a network of people skilled and available to coach older 

Mainers in attaining and maintaining a healthy lifestyle; and 3) increased communication and 

referrals among health care providers, community service organizations, and older adults. 




Project Title: Living Well -Take Charge of Your Health 






Contact: 

Judy R. Simon, MS, RD, LDN 

Tel. No. (410) 767-1090 

Email: JSimon@ooa.state.md.us 


Fiscal 

Year 

Funding 

Amounts 









Total $1,000,000 


The Maryland Department of Aging and its partners, the Department of Health and Mental 

Hygiene, the Governor's Office of Community Initiatives, Office of Service and Volunteerism, 

Rural Maryland Council, Towson University, and two health insurance companies are 

implementing this initiative. The goal is to encourage older people to take charge of their 

health through the Chronic Disease Self-Management Program (CDSMP) in six Planning 

Service Areas (PSAs), and the Active for Life program in one of those six. The approach is to 

develop state and local partnerships, including AAAs, aging services provider organizations 

(ASPO), local health departments (LHD), health care providers, faith-based organizations, 

and other agencies in their jurisdictions to provide the CDSMP in many settings, promoting 

the program and making it widely available. The objectives are to: 1) enhance capacity to 

provide the CDSMP through licensing and training; 2) develop new and enhance existing 

partnerships for broad application of the CDSMP and for sustainability; 3) provide 

opportunities for 2,661 participants in CDSMP and 75 in Active for Life; 4) develop outreach 

and referral for potential leaders and participants; 5) evaluate the projects for quality and 

effectiveness; and 6) disseminate project information nationally and statewide. The expected 

outcomes include: 1) CDSMP will be available to participants in a variety of settings; 2) health 

care providers will make referrals to the evidence-based (EB) projects; 3) participants will 

demonstrate outcomes as expected by the interventions; and 4) local partnerships, led by 

AAAs, ASPOs, and LHDs, will act as mentors to non-participating jurisdictions to enable them 

to develop EB projects in their areas. 








Policy and Program Development 

One Ashburton Place 


Contact: 

Ruth Palombo, PhD 

Tel. No. (617) 222-7512 



Fiscal 

Year 

Funding 

Amounts 









Total $825,000 


The Massachusetts Executive Office of Elder Affairs (Elder Affairs) and its partner, the 

Department of Public Health Office of Healthy Aging/Health and Disability (MDPH) is 

implementing evidence-based prevention programs with the goal of developing a sustainable 

infrastructure within the Commonwealth to implement high-quality evidence-based disease 

prevention (EBDP) programs that provide the maximum number of at risk older adults and 

people with disabilities the tools to maintain healthy and active lifestyles. Elder Affairs and 

MDPH will partner with community-based organizations and provide leadership for the 

implementation and evaluation of the following EBDP programs in three geographic areas: 1) 

Stanford University's Chronic Disease Self-Management Program in the Northeast Area; 2) A 

Matter of Balance in Boston; and 3) Healthy Eating for Successful Living in Older Adults in 

the South Suburban area. The major objectives are to: 1) build and sustain private/public 

partnerships at the state and local levels to deliver EBDP programs; 2) create protocols and 

guidelines for implementation, evaluation, and reporting; 3) provide EBDP programs to reach 

older adults and people with disabilities; 4) monitor the project's progress, fidelity, and 

outcomes; and 5) effect statewide and local policy and systems to sustain the project. The 

expected outcomes are: 1) existing public/private partnerships will expand their capacity to 

integrate EBDP programs into local and statewide systems; 2) older adults and people with 

disabilities will report improvements in falls; 3) better strategies for coping with diseases; 

better food choices; and 4) increased levels of physical activity. 




Project Title: Michigan's Older Adults: On the PATH to Better Health 



Michigan Department of Community Health 

Community Services 

PO Box 30676 

Lansing, MI 48909-8176 

Contact: 

Sherri C. King 

Tel. No. (517) 373-4064 

Email: kings1@michigan.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $825,000 


The Michigan Office of Services to the Aging (OSA) and the Michigan Department of 

Community Health (MDCH) support this grant. The goal is to create a sustainable statewide 

infrastructure that can facilitate the integration and embedding of evidence-based disease 

prevention programming into the local aging and public health networks. The objectives are 

to: 1) expand and enhance the capacity of the existing statewide group, Partners on the 

PATH (Personal Action Toward Health); 2) form community coalitions to oversee local 

provision of services; 3) ensure these coalitions have a sustainable business plan; 4) recruit 

and train program leaders; 5) develop a universal system to use for evaluation and to monitor 

fidelity; 6) provide follow-up and referral to participants; and 7) disseminate project 

information and develop a template for other area agencies on aging to recreate. The 

expected outcomes of this project are: 1) Partners on the PATH will become a line item in 

the state budget and will be instrumental in making recommendations on state policy 

concerning chronic disease; 2) local coalitions will have a sustainable marketing plan and 

oversee classes offered; 3) seniors who participate in classes will reduce their risk of 

developing chronic diseases; 4) seniors with chronic diseases will adopt better health 

practices that will improve their quality of life; 5) pre-and-post testing will reflect an increased 

knowledge in dealing with chronic diseases; and 6) documented fidelity to the programs will 

be realized. 




Project Title: Minnesota's Evidence-Based Health Promotion Initiative 




PO Box 64976 

St. Paul, MN 55164-0976 

Contact: 

Jean Wood 

Tel. No. (651) 431-2563 

Email: jean.wood@state.mn.us 


Fiscal 

Year 

Funding 

Amounts 









Total $825,000 


The Minnesota Board on Aging in partnership with the Minnesota Department of Health is 

working with public and private partners at the state and community levels to build a 

sustainable, statewide-coordinated evidence-based health promotion initiative. The 

objectives are to: 1) implement three highly visible, evidence-based health promotion 

programs - The Chronic Disease Self-Management Program, Matter of Balance, a fall 

prevention program, and Enhance Fitness, a physical activity program; 2) collaborate with 

strategic partners who can ensure identification of at-risk individuals and consistent referrals 

to these programs and who have a stake in the outcomes; 3) refine and expand data and 

quality assurance systems that can be used by all aging services providers to track 

participation in these programs and assure fidelity of implementation; and 4) build a business 

case for these approaches to ensure their long-term sustainability. The expected outcomes 

of this initiative are: 1) older Minnesotans will have fewer falls and fall-related injuries, 

maximizing their independence and quality of life; and 2) more older Minnesotans will adopt 

self-management skills and work with their health care providers to more effectively manage 

their chronic conditions, contributing to improvement of health status, independence and 

quality of life. 



Grant Number: 903116 





PO Box 360 

Trenton, NJ 08625 

Contact: 

Geraldine Mackenzie 

Tel. No. (609) 943-3499 

Email: geraldine.mackenzie@doh.state.nj.us 


Fiscal 

Year 

Funding 

Amounts 









Total $865,341 


The New Jersey Department of Health and Senior Services (DHSS) is developing statewide 

capacity for local delivery of low-cost, evidence-based disease prevention programs 

(EBDPP). This grant is building upon New Jersey's model for healthy aging, which is based 

upon leadership and coordination within the Area Agency on Aging, program delivery through 

local community-based providers, and strategic partnerships with public health and other 

health care providers to assure the quality of health-related activities. The goal is to 

empower seniors to reduce modifiable risk factors for disease and disability by establishing 

the infrastructure to effectively deliver the Chronic Disease Self-Management Program 

(CDSMP) in Atlantic, Cape May, Warren and Ocean Counties, and the Healthy IDEAS 

program in Essex and Union Counties, the Matter of Balance (MOB) in Middlesex and Salem 

Counties. Objectives include: 1) establishing local partnerships for service delivery; 2) 

certifying master trainers and class leaders for CDSMP; 3) developing and delivering training 

for Healthy IDEAS; 4) implementing programs and integrating them into the counties' service 

delivery system; and 5) conducting a comprehensive evaluation. In addition, state level intra 

and inter-departmental partnerships will establish CDSMP in related networks, including 

Medicaid, Disabilities and Chronic Disease Services. Outcomes will be achieved on three 

levels: 1) participants will be empowered to better manage their chronic diseases through 

skill development and enhanced self-confidence; 2) the local service delivery system will 

have strengthened provider relationships and integrated delivery of EBDPP; and 3) the state 

will have a more fully developed model to support healthy aging statewide. Target audiences 

are underserved populations, including African-Americans, Latinos, frail individuals and those 

with access barriers. Products include evaluated templates for model replication, reports 

detailing evaluation outcomes, and written materials distributed electronically via listservs and 

websites. 




Project Title: Empowering Older New Yorkers To Take More Control of their 

Health 





Albany, NY 12223-1251 

Contact: 

Marcus Harazin 

Tel. No. (518) 474-6101 

Email: Marcus.Harazin@ofa.state.ny.us. 


Fiscal 

Year 

Funding 

Amounts 









Total $1,000,000 


The New York State Office for the Aging and its partner, the Department of Health, propose 

to implement evidence-based health promotion programs with the goal of building the 

capacity of local service delivery systems in New York State to incorporate and sustain 

implementation of the Chronic Disease Self- Management Program (CDSMP) and the Active 

Choices, physical activity program. Objectives are: 1) successfully implement CDSMP and 

DSMP programs in the Capital District Region (Albany, Rensselaer, Saratoga, and 

Schenectady Counties), Broome County, and New York City; 2) ensure fidelity to program 

protocols, encourage on-going quality improvement and guide systems change at the state 

and local level, thereby increasing the likelihood of sustainability upon the completion of the 

project's funding; and 3) disseminate a model for implementation and sustainability of 

evidence-based programs. Anticipated Outcomes: 1) improvement in health promotion 

participation and outcomes for residents over age 60; 2) integration of evidence-based 

programs into the health promotion offerings of the State and particularly in Point of Entry 

(POE) and Naturally Occurring Retirement Community Supportive Services Program 

Development; 3) greater integration of AAA and County Health Department efforts; and 4) 

new public/private support for evidence-based health promotion programs. 










Raleigh, NC 27699-2101 

Contact: 

Audrey Edmisten 

Tel. No. (919) 733-0440 

Email: audrey.edmisten@dhhs.nc.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $522,830 


The North Carolina Division of Aging and Adult Services and the Division of Public Health are 

using its AoA Evidence-based Disease Prevention Programs (EBDPs) grant to successfully 

implement and maintain Stanford University’s Chronic Disease Self-Management Program 

(CDSMP). The goal of the project is to significantly enhance the state’s existing EBDPs 

infrastructure to ensure stability and expand reach of EBDPs. The objectives are to: 1) pilot 

an EBDP infrastructure project in one Area Agency on Aging (AAA) region in order to 

streamline implementation and data collection of multiple EBDPs regionally disseminated 

plus provide the support needed to ensure fidelity and sustainability; and 2) expand 

implementation of “A Matter of Balance and Fit and Strong!” using AAAs as hubs of regional 

activities supporting ongoing sustainability and quality. The expected outcomes of the project 

are: 1)the pilot AAA will report more efficient implementation and more effective 

management of EBDPs; and 2) wider dissemination of A Matter of Balance and Fit and 

Strong! Our major products will include: data management system, data collection forms, 

fidelity monitoring tools, and a corps of EBDPs trainers and leaders/coaches. 




Project Title: Ohio's Evidence-Based Prevention Program Initiatives 






Contact: 

Marcus J. Molea 

Tel. No. (614) 752-9167 



Fiscal 

Year 

Funding 

Amounts 









Total $1,000,000 


The Ohio Departments of Aging (ODA) and Health (ODH), AAAs and community-based 

health care and aging service organizations are working to build a collaborative infrastructure 

aimed at improving the health of older Ohioans by implementing evidence-based prevention 

programs at the local level. The State is implementing and evaluating four different 

interventions focusing on Chronic Disease Self-Care: the Active Living Everyday program 

(ALED); the Chronic Disease Self-Management Program,(CDSMP), Matter of Balance (MoB); 

Healthy IDEAS (HI) in multiple regions of the state; and the Diabetes Self-Management 

Program (DSMP), which will begin in 2010. As of January 31, 2009, the state had trained: 

24 Master Trainers and 89 Group Leaders in CDSMP; 34 Master Trainers and 157 Group 

Leaders in MoB; 1 Master Trainer and 12 Instructors in ALED; and 53 Facilitators in Healthy 

IDEAS. CDSMP classes are being offered in 54 sites; MoB are being been offered in 42 

sites; and ALED are being offered in 11 sites. As of January 31, 2009, 686 persons had 

been enrolled in CDSMP; 652 had been enrolled in MoB; and 180 had been enrolled in 

ALED... Key project partners include: 8 of 12 Ohio Area Agencies on Aging; the Fairhill 

Center, Cleveland; the Hamilton County Health District, Cincinnati; the Cuyahoga County 

Health District, Cleveland;; and the LifeCare Alliance, Columbus. 




Project Title: Living Longer, Living Stronger: The Oklahoma Project 





State Capitol Complex - Sequoyah Building 

2400 North Lincoln Blvd. 


Contact: 

Zack Root 

Tel. No. (405) 521-2907 

Email: connie.schlittler@okdhs.org 


Fiscal 

Year 

Funding 

Amounts 









Total $1,000,000 


The Oklahoma Department of Human Services Aging Services Division, in partnership with 

the State Department of Health, is developing and implementing the Living Longer, Living 

Stronger project for persons 60 years and older in four rural regions. The partnership 

includes AAAs, aging services nonprofit providers, the Chickasaw Nation, and others within 

the collaborative network. The goal of the project is to increase the quality of life and 

decrease the complications of arthritis, heart disease, stroke, and obesity among persons 

residing in Oklahoma by providing the Enhance Fitness and Chronic Disease Self 

Management Programs. The project objectives are to: 1) develop and sustain quality 

implementation of two evidence-based health prevention programs for individuals 60 years of 

age and above; 2) improve collaboration in providing services among health, public health, 

and aging services network agencies at the state and local level; and 3) evaluate the 

program, document activities, and disseminate the results. Project outcomes are to: 1) 

provide evidence-based health prevention programs to 2,800 individuals over 60; 2) develop 

over 100 permanent program sites over three years; 3) improve health outcomes among 80% 

of participants; and 4) sustain the program once federal funding ends. The Oklahoma Project 

will produce an interagency advisory committee, a final report, marketing materials, articles 

for publication, data reflecting participants in Oklahoma, models for rural and tribal regions, 

and abstracts and workshops for national conferences. 




Project Title: Evidence-Based Prevention Programs for Older Adults in Oregon 






Salem, OR 97301-1076 

Contact: 

Elaine Young 

Phone: 503-373-1726 



Fiscal 

Year 

Funding 

Amounts 









Total $1,050,000 


The Oregon Dept. of Human Services, Seniors and People with Disabilities and the 

Department of Human Services, Health Promotion, and Chronic Disease Prevention are 

implementing an evidence-based (EB) disease prevention initiative with the goal of promoting 

the health and independence of community-living older adults in four diverse areas in Oregon 

and are additionally expanding state-wide in training and marketing to reach more older 

adults. In 2010-2011, Oregon is supporting the Chronic Disease Self-Management Program 

(CDSM) with their funding. CDSMP will promote active self-management of chronic 

conditions and promote physical activity. The objectives are to: 1) reach at-risk seniors with 

EB programs through new and expanded partnerships between aging, health, private, and 

public agencies; 2) maintain fidelity to the design and research outcomes associated with the 

selected interventions; 3) increase awareness and use of EB health promotion programs 

focused on older adults; and 4) develop systems that can be used in sustaining, replicating, 

and expanding the use of such programs in Oregon. The anticipated outcomes are: 1) reach 

190 participants; 2) identify new and expanded community partners to offer EB to at risk older 

adults; 3) increase participation by high risk older adults in EB programs to impact chronic 

disease self-management, physical activity and falls prevention; and 4) expand the project to 

additional counties, as a result of dissemination efforts. Products: final report, including data 

on participation and reach, and systems development; articles that may be written about the 

project; and logic models for implementation of each program, as well as abstracts for any 

conference presentations on the project. 




Project Title: Implementation of Evidence-Based Intervention Programs 

Statewide 





1301 Main Street, Suite 200 


Contact: 

Crystal K. Strong 

Tel. No. (803) 734-9908 

Email: CStrong@aging.sc.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $1,000,000 


The South Carolina Lieutenant Governor's Office on Aging and its partner, the Department of 

Health and Environmental Control will continue to provide proven prevention programs with 

the following goals and objectives. Goal 1 - Iincrease the quality and years of life for older 

adults with chronic diseases or fear of falling with the objectives of 1) expanding the Chronic 

Disease Self-Management Program (CDSMP) statewide; 2) implementing A Matter of 

Balance fall prevention program (MOB) in two regions; 3) training additional Group Leaders 

and Master Trainers; 4) expanding health promotion strategies and materials to reach diverse 

groups, including underserved populations; and 5) continuing to evaluate the reach, fidelity, 

and impact of the programs. Goal 2 - Maintain and expand the infrastructure of partnerships 

to embed these programs in state health and long-term care systems with the objectives of: 

1) strengthening and expanding the local partnership base; 2) providing leadership, 

consultation, and ongoing support to local partners; 3) sustaining and expanding the 

commitment of funds and resources from public and private sectors; and 4) strengthening 

and expanding the South Carolina Partnership for Healthy Aging. Outcomes include: 1) 

CDSMP participants will report increased self-confidence, improved health status, and 

increased self-management behaviors; 2) MOB participants will demonstrate a reduced fear 

of falling and increased mobility: and an increased number and reach of evidence-based 

prevention programs for older adults in the state, and reductions in health care utilization and 

costs. 




Project Title: Texas Healthy Lifestyles 




Center for Policy and Innovation 

701 W. 51st St. 


Contact: 

Christy Fair 

Tel. No. (512) 438-3257 



Fiscal 

Year 

Funding 

Amounts 






FY2005 



Total $999,999 


The State of Texas, through the Department of Aging and Disability Services and the 

Department of State Health Services, under the umbrella of "Aging Texas Well," and in 

cooperation with the Bexar AAA, the Brazos Valley AAA and Neighborhood Centers Inc., is 

expanding regional public/private evidence-based health promotion to help seniors take 

control of their lives and reduce their risk of disease and disability. The goal is to create a 

focal point at the state level for evidence-based programs under the Aging Texas Well (ATW) 

Initiative and expand the scope of these programs through the faith-based community, in 

rural areas, and non-traditional partnerships. The planned interventions are the Chronic 

Disease Self-Management Program, the Matter of Balance fall prevention program, and 

Enhance Fitness. The objectives are: 1) to develop a foundation of knowledge of the risks 

associated with chronic disease and the benefits of a healthier lifestyle; 2) to help older 

persons learn to take responsibility for day to-day self management of their disease; 3) to 

increase awareness of local resources for a healthier lifestyle; 4) to reduce the burden of 

chronic illness across the participating regions of Texas; 5) to incorporate a more 

comprehensive approach to chronic disease management as part of ATW; and 6) to 

disseminate project information at the conclusion of the grant term. The outcomes will be: 

improved self-efficacy (for chronic disease management), improved self-reported health 

status and symptom management, improved health behaviors, reduced utilization of 

healthcare resources, and stronger community resources to support non-medical chronic 

disease management. 




Project Title: Living Well in Wisconsin 



Wisconsin Department of Health and Family Services 



PO Box 7850 

Madison, Wisconsin 53708-7850 

Contact: 

Gail Schwersenska 

Tel. No. (608) 266-7803 

Email: SchweGA@dhfs.state.wi.us 


Fiscal 

Year 

Funding 

Amounts 









Total $1,100.000 


The Wisconsin Department of Health and Family Service's Divisions of Long Term Care and 

Public Health are conducting evidence-based injury and disease prevention programs and 

Chronic Disease Self Management Programs (CDSMP) in collaboration with AAAs, local 

county/tribal aging agencies and public health departments, health care providers, the 

Wisconsin Medical Society, and others. The project goals for 2010-2011 are to: 1) continue 

to support the implementation of CDSMP and Stepping On; and 2) to implement the 

Medications Management Improvement System (MMIS) which is an evidence-based tool that 

reduces falls in older adults by addressing polypharmacy. Objectives are to: 1) promote selfmanagement 

of chronic conditions and reduce falls in older adults through the CDSMP and 

Stepping On programs; 2) develop MMIS infrastructure by providing small implementation 

grants to develop programs; and 3) partner with local pharmacists who can serve as program 

consultants. Expected outcomes are to reach 500 older adults to: 1) reduce unnecessary 

therapeutic duplications of the same drug; 2) reduce falls, dizziness or confusion caused by 

inappropriate psychotropic drugs; 3) reduce cardiovascular medication programs related to 

dizziness, and 4) reduce inappropriate use of non-steroidal anti-inflammatory drugs. 


Evidence-Based Disease Prevention Programs – National Resource 

Center 

The Administration on Aging (AoA) held a cooperative agreement grant competition to 

support a National Resource Center to assist State grantees develop the workforce and 

systems to deliver Evidence-Based Disease and Disability Prevention (EBDP) programs. 

AoA currently supports 24 states operating EBDP programs at 1,200 community-based 

delivery sites. The EBDP includes national training and certification programs; a national 

resource center on evidence-based prevention programs for the elderly; local program 

training materials, guides and marketing materials; quality assurance mechanisms and fidelity 

protocols. 

Information about the Center and the Evidence-Based Disease and Disability Prevention 

programs can be read on the AoA website: 



Program: Evidence-Based Prevention -National Resource Center 


Project Title: Evidence-Based Prevention Programs-National Resource Center 

Project Period: 09/30/2003 – 02/31/20101 


National Council on the Aging 

1901 L Street, NW 


Contact: 

Wendy Zenker 

Tel. No. (202) 479-6618 



Fiscal 

Year 

Funding 

Amounts 


FY2009 $1,300,000 







Total $5,562,000 


The National Council on the Aging (NCOA) established a National Resource Center to 

support prevention demonstration grantees to successfully implement evidence-based 

disability and disease prevention programs; engage the aging services network (and others) 

in evidence-based programs and facilitate their adoption; and assist AoA to further develop 

an evidence-based prevention program. The outcomes of this project are replicable 

programs that can positively affect the health and function of older adults, and increased 

support for the aging network's contributions in addressing prevention needs. The Center 

leverages NCOA's experience in strengthening the capacity of aging service providers to 

offer evidence-based programming and provide multiple types of resources and technical 

assistance. Bringing complementary skills and knowledge are the Center's partners - the 

Aging Blueprint Office, the Healthy Aging Research Network of CDC's Prevention Research 

Centers, UCLA's Geriatric Medicine and Gerontology Program, a leading communications 

and dissemination firm, and leading national aging organizations. Support of the National 

Resource Center was re-competed in FY2010 and supported under a new project grant 

award. 


Program: Evidence-Based Disease Prevention – National Resource Center 

Grant Number: 90BP0001 

Project Title: National Resource Center - Supporting States Developing 

Evidence-Based Disease Prevention Programs and Delivery 

Systems 



National Council on Aging, Inc. 

1901 L. Street, NW 4 th Floor 

Washington DC 20036 

Contact: 

Wendy Zenker 

Tel. No. (202) 479-6618 



Fiscal 

Year 

Funding 

Amounts 









Total $650,000 


The National Council on the Aging (NCOA) serves as the National Resource Center to 

support the Administration on Aging’s evidence-based prevention programs in 24 states. 

These programs address topics such as healthy behaviors, exercise, medication 

management, and depression. The Center’s goals are to help grantees implement and 

sustain these programs in partnership with public health programs. Technical assistance 

involves individualized assistance, tutorials, webinars, on-line education modules, tools and 

research designed to support the entire aging services network (and others) as they 

implement and sustain evidence-based programs. The outcomes of this project are: 1) 

replicable programs that can positively affect the health and function of older adults, and 2) 

increased support for the aging network's contributions in addressing prevention needs. 


Evidence-Based Disease Prevention Programs – Evaluation Design 

The Administration on Aging (AoA) and the Centers for Disease Control and Disease 

Prevention (CDC) have been collaborating since 2002 to promote increased collaboration 

between the public health and aging services networks, and to support health promotion and 

disease prevention programs for older adults at the state and local level. Beginning in 

FY2003 with small grants to ten States through the National Association of State Units on 

Aging (now National Association for States Aging United for Aging and Disabilities), this 

collaboration has supported implementation of evidence-based health promotion and disease 

prevention programs. 

CDC supports a sub-set of its Prevention Research Centers as a collaborative Healthy Aging 

Research Network including the Texas A & M University Health Science Center. AoA 

awarded a grant to the Center in FY2008 for development of an evaluation design to assess 

the performance of the State grants it has awarded since FY2006 under its Evidence-Based 

Disease and Disability Prevention Program. The grant also is designed to provide states with 

tools to improve the implementation and delivery of EBPs in terms of reach and adoption, 

treatment fidelity, cost-effectiveness, and sustainability, ultimately leading to the 

enhancement of seniors' health and well-being. In addition to summary briefing reports and 

scholarly publications, specific products include a research update, plan for online evaluator 

training modules, guidebook for applying cost-effectiveness methodology, and compendium 

of best practices. 


Program: Evidence Based Disease Prevention 

Grant Number: 90OP0001 

Project Title: Planning a Nationwide Evaluation of Evidence-Based Programs 

for Seniors 



Texas A&M University System 

School of Rural Public Health 

400 Harvey Mitchell Parkway South, Suite 100 

College Station, TX 77845 

Contact: 

Marcia Ory 

Tel. (979) 458-1373 

Email: mory@srph.tamhsc.edu 

AoA Project Officer: Jane 

Fiscal 

Year 

Funding 

Amounts 









Total $900,000 


The Texas A&M Health Science Center, School of Rural Public Health, with support from the 

Centers for Disease Control's Prevention Research Center-Healthy Aging Research Network, 

will develop a comprehensive plan for a nationwide evaluation of evidence-based programs 

(EBP) for seniors. The four major objectives are: 1) to assess the current state of knowledge 

about EBP practice and evaluation; 2) to identify strengths and gaps in reaching aging 

populations, delivering EBP services, and building training and evaluation capacity; 3) to 

recommend a nationwide evaluation plan, specifying design, measurement, desired 

outcomes, and other critical elements; and 4) to indicate key players/areas of expertise 

needed to conduct the proposed evaluation plan. The primary outcome will be a 

recommended plan to evaluate EBPs for older adults nationwide, in collaboration with the 

National Association of State Units on Aging, National Association of Area Agencies on 

Aging, and aging services provider organizations. Secondary outcomes are to improve the 

implementation and delivery of EBPs in terms of 1) reach and adoption; 2) treatment fidelity; 

3) cost-effectiveness; and 4) sustainability: which ultimately lead to the enhancement of 

seniors' health and well-being. In addition to summary briefing reports and scholarly 

publications, specific products include a: research update, plan for online evaluator training 

modules, guidebook for applying cost-effectiveness methodology, and compendium of best 

practices. The intent of the project is to mobilize key stakeholders in synergistic partnership to 

help define and facilitate implementation of a nationwide evaluation effort developed with 

input from the aging services network, public health arena, and health care sector. 


Next Generation - Performance Outcome Measurement Project (POMP) 

The Administration on Aging (AoA) held a project grant competition in FY2008 for States to 

build on the work of the Performance Outcome Measurement Project of previous years and 

to continue to enhance performance measurement capability throughout the Aging Network. 

The Government Performance and Results Act requires Federal agencies to use 

performance measurement, particularly outcome measurement, to improve the performance 

of Federal programs. Further, the Office of Management and Budget implemented a 

performance assessment process which placed increased emphasis on assessing program 

performance through outcome measurement. Results from earlier POMP projects were 

instrumental in improving AoA’s program assessment scores. 

Over the past nine years, AoA has sponsored the Performance Outcome Measurement 

Project for the Older Americans Act (OAA), Title III programs. This project with State Units 

on Aging and Area Agencies on Aging (AAAs) has produced a core set of performance 

measurement instruments. The instruments have been developed to obtain consumerreported 

outcomes and quality assessment for critical OAA services. The instruments also 

measure special needs characteristics of the people receiving services. 

The new projects awarded in FY2008 and continuing in FY2010 encompass developmental 

and planning work for Next Generation: POMP and the development and preparation of a 

“POMP TO GO” toolkit. POMP efforts so far have created surveys that interested entities can 

implement to measure service-specific outcomes. The toolkit will assist the aging network 

and other interested parties in conducting surveys and using the information collected for 

program improvement and budget justification. Next Generation: POMP grantees were also 

asked to do developmental work on predictive modeling of nursing home placement using 

existing POMP survey data, participate in the development of longitudinal surveys to 

compliment the cross-sectional information of existing POMP surveys and to validate the 

nursing home predictor model that is currently being developed and to enhance its utility at 

the national level through replication and inclusion of community context variables (nursing 

home bed supply, community characteristics). 

Additional information about POMP can be found on this website: 

https://www.gpra.net/default.asp 


Program: Next Generation - Performance Outcomes Measurement Project 

Grant Number: 90NG0007 

Project Title: Arizona Next Generation: Performance Outcome 

Measurement Project 







Contact: 

John Kinkel 

Tel. (602) 364-1974 

Email: jkinkel@azdes.gov 

AoA Project Officer: Cynthia A. Bauer 

Fiscal 

Year 

Funding 

Amounts 









Total $168,032 


The goal for the Next Generation: Performance Outcome Measure Projects (POMP) is 

enhanced performance measurement capacity throughout the Aging Network. This project, 

the first phase of the Next Generation: POMP is developmental. Its objectives are: 1) the 

development of the "POMP TO GO" toolkit; 2) the development of longitudinal performance 

measurement surveys; 3) the development of a methodology to cross-validate the generic 

nursing home predictor model being developed under Advanced POMP; and 4) the 

development of a plan to assess the nursing home predictive value of key performance 

measure variables in earlier POMP surveys. Arizona is assuming a leadership role for the 

development of longitudinal surveys. 




Project Title: Florida Next Generation: Performance Outcome 







Contact: 

Jay Breeze 

Tel. (850) 414-2338 



Fiscal 

Year 

Funding 

Amounts 









Total $159,645 


The goal for the Next Generation: POMP project is enhanced performance measurement 

capacity throughout the Aging Network. This project, the first phase of the Next Generation: 

Performance Outcome Measurement Project (POMP), is developmental. Its objectives are: 

1) the development of the "POMP TO GO" toolkit; 2) the development of longitudinal 

performance measurement surveys; 3) the development of a methodology to cross-validate 

the nursing home predictor model being developed under Advanced POMP; and 4) the 

development of a plan to assess the nursing home predictive value of performance 

measurement variables included in earlier POMP surveys. Florida is assuming a leadership 

role in developing a plan to assess the predictive value of performance measures identified in 

earlier POMP surveys. 




Project Title: Next Generation: Performance Outcome Measurement Project 





2 Peachtree Street, N.W., Suite 9-398 

Atlanta, GA 30303-3142 

Contact: 

Elaine Popham 

Tel. (912) 449-4996 

Email: mepopham@dhr.state.ga.us 


Fiscal 

Year 

Funding 

Amounts 









Total $92,170 


The goal for Next Generation POMP is enhanced Performance measurement capacity 

throughout the Aging Network. This project, the first phase of the Next Generation: 

Performance Outcome Measurement (POMP), is developmental. Its objectives are: 1) the 

development of the "POMP TO GO" toolkit; 2) the development of longitudinal performance 

measurement survey instruments; 3) the development of a methodology to cross-validate the 

nursing home predictor model under development in Advanced POMP; and 4) the 

development of a plan to identify nursing home predictive value of performance measurement 

variables included in earlier POMP surveys. Georgia is assuming a leadership role in the 

development of the "POMP TO GO" toolkit. 




Project Title: Massachusetts Next Generation Performance Outcome 




Massachusetts Executive Office on Aging 

One Ashburton Place, 5th Floor 


Contact: 

Ruth Palombo 

Tel. (617) 222-7514 



Fiscal 

Year 

Funding 

Amounts 









Total $179,948 


The goal for the Next Generation POMP project is enhanced performance measurement 


Performance Outcome Measurement Project (POMP) is developmental. Its objectives are: 1) 

the development of the "POMP TO GO" toolkit; 2) the development of longitudinal 

performance measurement survey instruments; 3) the development of a methodology to 

cross-validate the nursing home predictor model being developed under Advanced POMP; 

and 4) the development of a strategy to assess the nursing home predictive value of key 

performance measurement variables from earlier POMP surveys. Massachusetts has 

assumed a leadership role in the development of "POMP TO GO" toolkit. 




Project Title: Next Generation: Performance Outcome Measurement Project 





Albany, NY 12223 

Contact: 

I-Hsin Wu 

Tel. (518) 486-2730 

Email: i wu@ofa.state.ny.us 


Fiscal 

Year 

Funding 

Amounts 









Total $180,000 


The goal for the Next Generation: POMP project is enhanced performance measurement 


Performance Outcome Measurement Project (POMP) is developmental. Its objectives are: 1) 

the development of the "POMP TO GO" toolkit; 2) the development of longitudinal 


cross-validate the nursing home predictor model under development in Advanced POMP; 

and 4) the development of a strategy to assess the nursing home predictive value of key 

performance measurement variables of earlier POMP surveys. New York is assuming a 

leadership role for developing a methodology to cross-validate the nursing home predictor 

model developed under Advanced POMP. 




Project Title: Next Generation: Performance Outcome Measures (POMP) 






Raleigh, NC 27699-2001 

Contact: 

Phyllis Bridgeman 

Tel. (919) 733-0440 

Email: phyllis.bridgeman@ncmail.net 


Fiscal 

Year 

Funding 

Amounts 









Total $180,000 


The goal for the Next Generation POMP project is enhanced performance measurement 


Performance Outcome Measurement Project (POMP), is developmental. Its objectives are: 



cross-validate the nursing home predictor model developed under Advanced POMP; and 4) 

the development of a plan to assess the nursing home predictive value of key performance 

measurement variables included in earlier POMP surveys. North Carolina is assuming a 

leadership role in the development of longitudinal performance measurement instruments. 




Project Title: Ohio's Next Generation Performane Ooutcomes Measurement 

Project 





Columbus, OH 43215 

Contact: 

Robert Lucas 

Tel. (614) 6441471 

Email: rlucas@age.state.oh.us 


Fiscal 

Year 

Funding 

Amounts 









Total $180,000 


The overall for the Next Generation: POMP is enhanced performance measurement capacity 

throughout the Aging Network. This project, the first phase of the Next Generation: 

Performance Outcome Measurement Project (POMP) is developmental. Its objectives are: 


performance measurement surveys; 3) the development of a methodology to cross-validate 

the generic nursing home predictor model being developed under Advanced POMP; and 4) 

the development of a plan to assess the nursing home predictive value of key performance 

measure variables in earlier POMP surveys. AoA is assuming a leadership role for final 

survey content. 


Center for Program Operations 

The Administration on Aging (AoA) Center for Program Operations provides plans and directs 

the programs under the Older Americans Act designed to provide planning, coordination and 

services to older Americans through grant programs authorized under Titles II, III, VI, and VII. 

The project grants in this section are administered by the Center’s four major units: The 

Office of Home and Community Based Services; the Office of Elder Rights; the Office of 

American Indian, Alaskan Native, and Native Hawaiian Programs; and the Office of Outreach 

and Consumer Information. 


Lifespan Respite Care Program 

Lifespan Respite Care programs are coordinated systems of accessible, community-based 

respite care services for family caregivers of children or adults of all ages with special needs. 

Eligible state agencies funded are using grant funds for the purposes of planning, 

establishing and expanding/enhancing Lifespan Respite Care systems in the states, including 

new and planned emergency respite services, training and recruiting respite workers and 

volunteers and assisting caregivers with gaining access to needed services. Eligible 

recipients of respite services under this Program Announcement include family members, 

foster parents, or other adults providing unpaid care to adults who require care to meet basic 

needs or prevent injury and to children who require care beyond that required to meet the 

basic needs of the child. 

The Administration on Aging (AoA) held its second year grant competition for State 

government agencies in FY2010 awarding twelve (12) projects. 

Information about the Lifespan Respite Care Program is located on the AoA website: 

http://www.aoa.gov/AoARoot/AoA Programs/HCLTC/LRCP/index.aspx 


Program: Lifespan Respite Care Program 

Grant Number: 90LR0013 

Project Title: Delaware Lifespan Respite Care Program 




Aging and Disablities 

1901 N. duPont Highway 

New Castle, DE 19720-1160 

Contact 

Guy Perrotti 

Tel. No. (302) 255-9364 

Email: guy.perrotti@state.de.us 

AoA Project Officer: Gregory Link 

Fiscal 

Year 

Funding 

Amounts 









Total $188,432 


The Delaware Division of Services for Aging and Adults with Physical Disabilities (DSAAPD), 

in partnership with the Delaware Lifespan Respite Care Network (DLRCN) and key 

stakeholders will expand and maintain a statewide coordinated lifespan respite system that 

builds on the infrastructure currently in place. The goal of this project is to improve the 

delivery and quality of respite services available to families across age and disability 

spectrums by expanding and coordinating existing respite systems in Delaware. The 

objectives are: 1) to improve lifespan respite infrastructure; 2) to improve the provision of 

information and awareness about respite service; 3) to streamline access to respite services 

through the Delaware ADRC; 4) to increase availability of respite services. Anticipated 

outcomes include: 1) families and caregivers of all ages and disabilities will have greater 

options for choosing a respite provider; 2) providers will demonstrate increased ability to 

provide specialized respite care; 3) families will have streamlined access to information and 

satisfaction with respite services; 4) respite care will be provided using a variety of existing 

funding sources and 5) a sustainability plan will be developed to support the project in the 

future. The expected products are marketing and outreach materials, caregiver training, 

respite worker training, a Respite Online searchable database, two new Caregiver Resource 

Centers (CRC), an annual Respite Summit, a respite voucher program and 24/7 telephone 

information and referral services. 




Project Title: Kansas Lifespan Respite Project 




403 S. Kansas Ave. 


Contact 

Tina Langley 

Tel. No. (785) 368-7331 



Fiscal 

Year 

Funding 

Amounts 









Total $188,221 


Kansas Department on Aging (KDOA), in collaboration with the Kansas Lifespan Respite 

Coalition, Aging and Disability Resource Centers (ADRCs) and the Kansas Department of 

Social and Rehabilitation Services supports the development of the Kansas Lifespan Respite 

Project. The goal of the Project will be to expand access to and improve the quality of respite 

services for residents across the state, regardless of age, disability or special need. Led by 

the Kansas Department on Aging (KDOA), three objectives will be achieved: 1) expand 

coordination, participation and dissemination of respite resources resulting in a statewide 

respite network; 2) increase family caregiver access to and ease in securing respite 

providers; and 3) increase availability of qualified respite providers and skilled caregivers 

statewide. Anticipated outcomes include: 1) coordinated respite provider services and 

information through enhancement of KDOA’s ADRC website; 2) increased public awareness 

of respite through innovative information campaign; 3) increased caregiver knowledge and 

access through one-stop point of service; 4) increased training opportunities for family 

caregivers and respite professionals; and 5) adoption of long-term sustainability plan. 

Products from the project will include an enhanced/expanded website; enhanced/expanded 

ADRC Online Resource Manual; information campaign materials (brochures, fact sheets, 

news briefs) targeting the general public and non-English speaking individuals; quarterly 

progress and final reports to the U.S. Administration on Aging (AoA); evaluation findings; and 

training curricula. 




Project Title: Louisiana Lifespan Respite Project 



Louisiana Department of Health and Hospitals 

628 N. Street 

Baton Rouge, LA 70821- 2031 

Contact 

Hugh Eley 

Tel. No. (225) 342-1981 

Email: hugh.eley@la.gov 



Fiscal 

Year 

Funding 

Amounts 









Total $188,838 

The Louisiana Lifespan Respite Project in collaboration with a broad base of consumer and 

provider organizations and managed by the Louisiana Lifespan Respite Coalition supports 

this project to build and expand coordinated long-term care services in Louisiana. The goal 

of the Lifespan Respite Care Project in Louisiana is to provide a statewide, comprehensive, 

and coordinated approach to meet the lifespan respite care needs for Louisiana’s family 

caregivers of individuals with disabilities and/or chronic conditions. Major objectives include: 

1) formalizing and expanding the Louisiana Lifespan Coalition; 2) updating the statewide 

database of long-term care services, particularly as it relates to respite care services; 3) 

marketing Louisiana’s Aging and Disability Resource Centers as the premier source of 

information about respite care; 4) educating consumers, providers, and funders about the 

definition, the benefits of and the need for respite care, including the most efficient methods 

of providing respite care in Louisiana; and 5) promoting education and training for family 

caregivers to increase the availability of informal respite care. Anticipated outcomes include: 

1) enhanced and coordinated information available about respite care services available for 

care recipient throughout the lifespan; 2) increased consumer knowledge of and acceptance 

of respite services; and 3) increased the availability of lifespan respite care throughout the 

state. Project products include enhanced information on state web sites, a ‘how-to’ manual 

for program implementation, and progress reports as required. 




Project Title: Lifespan Respite Care Program 



Massachusetts Department of Mental Retardation 

500 Harrison Ave. 


Contact 

Amy Nazaire 

Tel. No. (978) 774-5000 

Email: amy.nazaire@state.ma.us 



Fiscal 

Year 

Funding 

Amounts 

FY2010 $188, 950 








Total $188,950 

The Massachusetts Department of Developmental Services (DDS), in conjunction with the 

Massachusetts Respite Coalition, seeks to create a statewide Lifespan Respite Program, the 

goal of which is to increase availability of respite for all populations by creating a centralized, 

comprehensive statewide information, referral and training process for respite services. The 

Grant Implementation Team and the Massachusetts Respite Coalition will convene an 

Advisory Committee and Board of Directors to achieve this goal and the following objectives: 

1) develop a statewide respite coalition consisting of family caregivers, respite providers, and 

members of the aging, disability and health services networks; 2) improve statewide 

dissemination and coordination of respite care by developing a comprehensive, accessible 

directory of services; and 3) enhance and expand the availability of Lifespan Respite 

Services in Massachusetts by improving training and recruitment of providers, and 

developing a strategic plan and list of policy recommendations. Anticipated outcomes 

include: 1) a more collaborative network of respite service providers; 2) an easily accessible, 

highly visible on-line and print-based guide to respite services; 3) a better trained corps of 

respite workers and volunteers; and 4) greater availability of respite services. Products will 

include a three-year plan for the development of a Lifespan Respite Services Program; a 

written assessment of respite services in Massachusetts; a web-and print-based directory of 

respite services in Massachusetts; a dedicated website; a set of quality and safety guidelines 

for respite providers; a toolkit for replication of a statewide respite program, including a cost 

analysis; a training curriculum for workers and volunteers; and a list of policy 

recommendations. 




Project Title: Minnesota’s Lifespan Respite Program 



Minnesota Department of Human Services 

Board on Aging 

PO Box 64976 

St. Paul, MN 55164-0976 

Contact 

Kari Benson 

Tel. (851) 431-7415 

Email: kari.benson@state.mn.us 


Fiscal 

Year 

Funding 

Amounts 









Total $188,950 


The Minnesota Board on Aging, in collaboration with the Minnesota Department of Human 

Services and the Minnesota Lifespan Respite Coalition, supports the development of a 

Lifespan Respite Care Program. The goal of the project is to improve access to and 

availability of lifespan respite services for Minnesota’s family caregivers. Proposed objectives 

are to: 1) jumpstart, train and support Regional Lifespan Respite Collaboratives; 2) enhance 

the listing of public and private lifespan respite resources on the State’s database; 3) expand 

the online Caregiver Link to provide family caregivers with information, resources and tools 

regarding respite resources; 4) train community members as ‘lifespan respite ambassadors’ 

to increase awareness of available respite services; 5) increase coordination among public 

programs to maximize recruiting, training and funding resources; and 6) increase consumer 

choice and control of respite services across the lifespan. The expected outcomes of this 

effort are: 1) family caregivers will have increased knowledge of available respite services 

and how to access them; 2) family caregivers will receive more respite services that better 

meet their needs; 3) service providers, advocates and community members will have 

increased knowledge of the needs of caregivers and how they can be a part of a community 

of care; and 4) state program staff will report increased frequency of sharing resources to 

recruit and train respite providers and to increase the availability of lifespan respite services. 

Project products will include the enhanced lifespan respite service listing on the statewide 

Information and Referral database and evaluation reports on the Regional Lifespan Respite 

Collaboratives and the success of the project in achieving expected outcomes. 




Project Title: Nebraska Lifespan Respite Care Program 




P.O. Box 95026 

Lincoln, NE 68509-0526 

Contact 

Sara Briggs 

Tel. (402) 471-4623 

Email: sarah.briggs@nebraska.gov 



Fiscal 

Year 

Funding 

Amounts 









Total $178,322 

The Nebraska Department of Health and Human Services, in partnership with the Nebraska 

Lifespan Respite Network and Answers4Families (ADRC) supports this grant to build upon 

the state’s Lifespan Respite Program. The goal of the project is to improve access to 

Nebraska’s Lifespan Respite Program. Project objectives include: 1) replacing existing 

antiquated database with a web-based system that incorporates the Nebraska Resource 

Referral System/Answers4Families (ADRC); 2) expand online assessment capacity; 3) 

expand peer support options available through the ADRC web site; 4) educate respite 

coordinators about the ADRC; 5) develop or identify a statewide caregiver crisis planning 

tool; 6) increase providers for crisis/emergency respite; 7) identify, develop and deliver 

training for first responders; 8) develop criteria for short-term crisis respite funding; and 9) 

expand awareness of available respite services. Anticipated outcomes include: 1) 

integration of Lifespan Respite Program information into the ADRC web site; 2) increased 

accessibility of provider information to families, caregivers and clients; 3) First Responders 

have resources for families in crisis; and 4) enhanced peer support options for family 

caregivers. Products will include an enhanced website, webinars and conference 

presentations, and lessons learned and mentoring to other states. 




Project Title: New York State Office for the Aging Lifespan Respite Care Program 

Project Period: 09/01/2010 – 09/01/2010 




Albany, NY 12223-1251 

Contact 

Gregary Olsen 

Tel. (518) 473-4552 

Email: g olsen@ofa.state.ny.us 



Fiscal 

Year 

Funding 

Amounts 









Total $188,950 

The New York State Office for the Aging (NYSOFA) supports this initiative in collaboration 

with the Statewide Caregiving and Respite coalition of New York (SCRCNY) and New York 

State’s ADRC (NY Connects) to form a NY Lifespan Respite Program Core Team to meet the 

following goal: expand and strengthen SCRCNY to build a caregiver support services 

network and develop a statewide coordinated system, increasing access to respite services 

for families across age/disability spectrums, including access to emergency respite services. 

Project objectives include: 1) develop a coordinated system of accessible, community-based 

respite services for people of all ages/across all needs; 2) conduct a statewide inventory of 

respite services and include in the statewide NY Connects database; 3) identify and facilitate 

development of respite services for underserved populations; 4) identify current programs 

that train informal caregivers and provide a methodology to link caregivers to programs; 5) 

determine good practices and establish linkages to recruitment and training of volunteers; 6) 

raise public awareness about caregiving and value of respite; and 7) develop a strategic 

approach to ensure sustainability. It is anticipated that New York will implement a lifespan 

respite program that build and strengthens SCRCNY and coordinates existing respite 

services across all sectors. Anticipated products include: a respite data base; a web-based 

good practices inventory, caregiver, volunteer and professional training materials; media 

materials; a final report, including program evaluation results; and abstracts for state and 

national conferences. 




Project Title: Oklahoma Lifespan Respite Project 




2401 NW23rd Street 


Contact 

Zackary Root 

Tel. (405) 522-3121 




Fiscal 

Year 

Funding 

Amounts 









Total $188,950 

The Oklahoma Department of Human Services, Aging Services Division, in partnership with 

the Oklahoma Respite Resource Network, Developmental Disabilities Services Division, Area 

Agencies on Aging, the Oklahoma State Departments of Health and Mental Health and 

Substance Abuse Services, and the Oklahoma Areawide Services Information System 

(OASIS) will implement the Lifespan Respite Care Program. The goal of the project is to 

provide respite services to the unserved and underserved caregiver population spanning the 

lifespan continuum in Oklahoma. Project objectives include: 1) provide technical assistance 

and seed grants to caregiver and disability-specific support groups, private and faith-based 

organizations and volunteer groups to start or enhance respite care services with a focus on 

sustainability; 2) provide respite vouchers to caregivers not eligible for funding; 3) enhance 

statewide outreach and recruitment efforts through public speaking engagements and 

development of promotional materials; and 4) strengthen training collaboration. Expected 

outcomes of the project include: 1) expanded respite services and choices for caregivers; 2) 

greater caregiver and care receiver independence; 3) reduction in the economic impact of 

out-of-pocket expense for respite services; 4) improved physical and mental well-being of the 

caregiver; and 5) enhanced training opportunities for caregivers and care recipients. 

Products from this project will include reports, statewide marketing and information materials, 

a respite guidebook, training materials; a cost-benefit analysis, links to a network of statewide 

respite resources via expanded websites and the ADRC; and evaluation results. 




Project Title: Pennsylvania Lifespan Respite Care Program 



Pennsylvania Department on Aging 

Bureau of Individual Support 

555 Walnut Street 

Harrisburg, PA 17101 -1925 

Contact 

Robert McNamara 

Tel. (717) 772-2541 

Email: rmcnamara@state.pa.us 


Fiscal 

Year 

Funding 

Amounts 









Total $187,015 


The Pennsylvania Department of Aging in partnership with the Pennsylvania Lifespan 

Respite Coalition, the Pennsylvania Departments of Public Welfare and Health, 

Pennsylvania’s network of Aging and Disability Resource Centers and key community based 

organizations will establish a statewide lifespan respite system. The goal of the project is to 

improve the coordination of and access to respite services across all ages and disabilities in 

the state. The following objectives will be addressed: 1) establish a statewide Lifespan 

Respite Care Advisory Council to lead, support and monitor the development of a lifespan 

respite care system for Pennsylvania; 2) improve coordination among state and local 

agencies and organizations that provide and/or fund respite services and those that provide 

information and referral to families; and 3) increase awareness of lifespan respite needs and 

services among caregivers and providers. Expected project outcomes are 1) improved 

statewide systems of coordination of respite services; 2) improved access to respite services 

for caregivers; and 3) increased awareness of respite needs and use of respite services. 

Products will include a comprehensive and culturally effective website for lifespan respite 

resources, including training resources and opportunities; a written action plan created by the 

Advisory Council that presents recommendations for efforts to sustain the created lifespan 

respite care system; and a report of evaluation results. 




Project Title: Utah Lifespan Respite Care Program 

Project Period: 09/01/2010-09/01/2011 



195 N 1950 St. 


Contact 

Sonnie Yudell 

Tel. (801) 539-3926 




Fiscal 

Year 

Funding 

Amounts 









Total $188,950 

The Utah Division of Aging and Adult Services, Utah Aging and Disability Resource Center 

(ADRC), Veteran’s Administration, Developmental Disabilities Council, National Alliance on 

Mental Illness Utah, Alzheimer’s Association and other agencies of the Utah Coalition for 

Caregiver Support (UCCS) will initiate a coordinated statewide lifespan respite care program; 

The goal of the project is to organize and integrate all of Utah’s respite care programs so that 

a single helpline and website meet the needs of caregivers searching for information, options 

and relief. The following objectives will be achieved: 1) institute a comprehensive lifespan 

respite care program with an accessible point of entry for caregivers; 2) expand respite care 

services and respite scholarships to family caregivers, and develop private funding sources to 

sustain lifespan respite scholarships; 3) implement a new “UCare” caregiver training program 

statewide for lifespan caregiver audiences and added modules related to the ADRC services 

and support to growing numbers of non-service connected Utah caregivers of Veterans with 

dementia; and 4) facilitate training and job access for candidates entering the field of 

professional caregiving and provide volunteer training for those desiring to provide lifespan 

respite care. Anticipated outcomes include: 1) an increased number of caregivers served; 2) 

increased consumer satisfaction; 3) and improved statewide coordination of lifespan respite 

care. Products include a final report, cost analysis, presentations and manual to support 

replication by other states, a web-based caregiver support center, statewide Access Utah 

Network telephone helpline, and a lifespan respite conference. 




Project Title: Wisconsin Lifespan Respite Care Program 






P.O. Box 7850 

Madison, WI 53707-7850 

Contact 

Beth Wroblewski 

Tel. (608) 267-5139 

Email: beth.wroblewski@wisconsin.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $188,950 


The Wisconsin Department of Health Services Division of Long Term Care, in collaboration 

with the Respite Care Association of Wisconsin (RCAW), Easter Seals Wisconsin, and the 

Wisconsin Quality Home Care Commission (WQJCC) will implement the Lifespan Respite 

Care Program. The goal of the project is to expand the availability and accessibility of respite 

services in Wisconsin. The following objectives will be achieved: 1) modify the Easter Seals 

Wisconsin Caring Network curriculum as a base-level, respite care provider training for 

people with special needs across the lifespan, including those with challenging behaviors; 2) 

deliver revised Caring Network curriculum in 6 different regions of the state; 3) deliver halfday 

workshops in 6 different regions for respite providers to learn best practices of caring for 

different special needs populations; 4) develop a public awareness campaign for RCAW 

about the need for respite providers; 5) implement the public awareness campaign; 6) 

expand WQHCC’s Care Registry referral database and matching services to include trained 

respite care workers; and 7) communicate respite provider trainings and expanded Care 

Registry to long-term care stakeholders. The following outcomes are anticipated: 1) trained 

respite providers will demonstrate knowledgeable skills to provide care for people with special 

needs across the lifespan, including those with challenging behaviors; and 2) families and 

caregivers will have more direct access to respite services in their communities. The 

following products will be created during the project: a provider training curriculum; a 

statewide home and respite care worker registry and matching service; a statewide public 

awareness campaign; and public awareness collateral materials, including print, web-based, 

video and a training curriculum. 




Project Title: Lifespan Respite Care Program 




640 Woodland Square Loop, SE 

Olympia, WA 08504-5600 

Contact 

Hilari Hauptman 

Tel. (360) 725 2556 

Email: 



Fiscal 

Year 

Funding 

Amounts 









Total $188,950 

The Aging and Disability Services Administration (ADSA) of Washington State is partnering 

with the Respite and Crisis Care Coalition of Washington (RCCCWA) in a three-year project 

to build a statewide lifespan respite care system. The goal of the project is to build, 

strengthen, and expand a sustainable statewide Lifespan Respite Care system and ensure 

that information is available to caregivers so that respite becomes more available and 

accessible to family caregivers throughout Washington State. Project objectives are: 1) build 

the capacity of RCCCWA through new and existing partnerships; 2) provide information to 

caregivers to give them the skills and confidence to recruit, hire, and work with respite 

providers; 3) collaborate on a statewide volunteer respite model for the recruitment, training, 

support and retention of volunteer respite providers; and 4) develop outreach strategies for 

caregivers, agencies, and the general public to inform them about the single point of entry for 

inquiries about respite care. Anticipated outcomes include: 1) family caregivers in 

Washington State will have an increased awareness of the availability of respite care; and 2) 

family caregivers in Washington State will have increased access to respite services. 

Products include a website and 1-800 number providing a single point of entry for caregivers 

seeking respite services, outreach materials in multiple languages about the range of respite 

care available, a booklet in multiple languages for caregivers on hiring and working with a 

respite provider; and a final report, including lessons learned and an evaluation of the 

project’s work. 


Technical Assistance Center for Caregiving and Lifelong Respite 

Programs 

In FY2009, AoA awarded a three year grant to the Family Caregiver Alliance in partnership 

with the ARCH National Respite Network to provide technical assistance for caregiver 

support and lifespan respite programs. 

The National Family Caregiver Program is a Title III Older Americans Act Program which 

awards formula driven grants to State Agencies on Aging. In FY2010 a continuation award to 

the partnership was award for its second year. 

Information about the National Family Caregiver and Lifelong Respite Programs are located 

on the AoA website: 

http://www.aoa.gov/AoARoot/AoA Programs/HCLTC/Caregiver/index.aspx 

http://www.aoa.gov/AoARoot/AoA Programs/HCLTC/LRCP/index.aspx 


Program: Technical Assistance for Caregiver and Lifespan Respite Care Programs 

Grant Number: 90PG0004 

Project Title: Technical Assistance for Caregiver and Lifespan Respite Programs 



Family Caregiver Alliance 

180 Montgomery Street, Suite #1100 

San Francisco, CA 94104 

Contact: 

Kathleen A. Kelly 

Tel. (415) 434-3388 

Email: kkelly@caregiver.org 

AoA Project Officer: Greg Link 

Fiscal 

Year 

Funding 

Amounts 









Total $731,622 


The Family Caregiver Alliance in partnership with ARCH National Respite Network supports 

the three-year Strengthening Professional Networks: Technical Assistance for Caregiver 

Support and Lifespan Respite Programs with the goal of increasing capacity, efficiency and 

effectiveness of caregiver support and lifespan respite networks (Networks) at state and local 

levels. The project’s objectives are: 1) To support Networks infrastructure development; 2) 

To develop and disseminate tools and resources for caregivers to the NFCSP and caregiver 

support programs; 3) To design and maintain a national respite care, technical assistance 

and information database; 4) To provide knowledge and competency tools and resources to 

Networks staff. Project outcomes include: increased efficiency of the Networks so the most 

benefit can be derived from the limited resources available; increased efficiency and 

effectiveness of the aging network through having the right tools and resources to address 

the changing needs of family caregivers; easy access to a database of respite resources so 

family caregivers can more effectively locate and use respite; increased competency of staff 

across the Networks through: 1) receipt of high quality training aimed at increasing 

knowledge and skills and 2) dissemination of practice standards for knowledge and 

competencies related to family caregivers developed at the national levels. The products 

included two websites offering national databases of respite programs and model caregiver 

support programs and materials; lifespan respite training materials; training modules; national 

and state conference workshops; monthly technical assistance emails; in-person and 

telephone technical assistance; practical tips for program developers; development of state 

children’s respite programs listings; web casts; dissemination of practice guidelines; final 

report; and abstracts for national conferences. 


Community Innovations for Aging in Place 

The 2006 Older Americans Act Amendments authorized support of demonstrations of 

neighborhood and community programs supporting aging in place with an emphasis on areas 

with high numbers of older residents aging in place. AoA first funded projects in FY2009, 

awarding three year demonstrations to fourteen (14) organizations and a technical assistance 

award to the Visiting Nurse Association of New York. Although diverse in their approaches, 

each demonstration emphasizes collaboration with organizations and agencies offering 

existing services which link residents to comprehensive and coordinated health and social 

services, including disease prevention and health promotion services, education, 

socialization, recreation and civic engagement. 

In FY2010 15 projects received their second year continuation funding. 

Additional information about Community Innovations for Aging in Place is found on the AoA 

website: 

http://www.aoa.gov/AoARoot/AoA Programs/HCLTC/CIAIP/Index.aspx 


Program: Community Innovations for Aging in Place 

Grant Number: 90AP2651 

Project Title: Alaska Native Aging in Place Project 



Mt. Sanford Tribal Consortium 

P.O. Box 357 

Gakona, AK 99586 

Contact: 

Evelyn Beeter 

Tel. (907) 822-5810 

Email: ebeeter@mstc.org 

AoA Project Officer: Greg B. Case 

Fiscal 

Year 

Funding 

Amounts 









Total $533,988 


In collaboration with the Alaska Native Tribal Health Consortium, University of Alaska and 

regional community college, State Senior and Disability Services and regional providers this 

project proposes the development of an Aging in Place program in two rural villages that will 

serve as a model for developing similar programs in other villages in Alaska. The goal of this 

three year demonstration project is to pilot an Aging in Place program in two rural Alaska 

Native villages to develop a cost effective, village based model that enables Native Elders to 

remain in their homes and villages during their remaining years of life. The objectives are: 1) 

collaborate with strategic partners to develop a village based program; 2) implement and 

evaluate services; and 3) disseminate process and outcome data and lessons learned to 

provide a model that can be adapted by other rural villages. The expected outcome is that 

the documentation of the project will provide an informative model and be of assistance to 

other Tribes in developing village based programs. Products include reports detailing 

evaluations of client services, and program development activities and outcomes and; a 

website that disseminates information and assistance to benefit rural Tribes in developing 

village based programs. 




Project Title: Catholic Charities Older Adult Outreach and Engagement Project 



Catholic Charities of Stockton 

1106 North El Dorado Street 

Stockton, CA 95202 

Contact: 

Kathi Toepel 

Tel. No. (209) 532-8448 

Email: ktoepel@ccstockton.org 


Fiscal 

Year 

Funding 

Amounts 









Total $528,926 


Catholic Charities - Diocese of Stockton proposes a three-year Older Adult Outreach and 

Engagement Project in collaboration with Tuolumne and Calaveras County's social service 

agencies, the Area Agency on Aging, and community organizations supporting the needs of 

older adults. The approach is to expand the current Older Adult Outreach and Engagement 

Program by adding new services and strengthening existing ones. The primary goal of the 

project is to provide a comprehensive, community-coordinated case management system 

that is responsive and addresses the diverse needs of older adults residing in rural area, 

enabling more elderly residents to safely age in place, continue to live independently in their 

community while retaining the dignity and respect they have earned. Objectives include: 1) 

increase assessment and intervention services which address both physical and 

psychosocial needs; 2) establish a senior home sharing program; 3) improve both physical 

and mental activity levels among elderly clients by strengthening already existing senior 

volunteer programs; and 4) creating a partnership between teen/young adults and seniors. 

The expected outcomes are that senior citizens can maintain an important level of 

independence enabling self-determination and increasing the level dignity necessary for a 

higher quality of life. The Senior Home Sharing program will expand seniors' housing options 

well beyond placement in long-term care facilities. Pre- and post-evaluations will be 

conducted with participants to accurately document baseline needs, challenges and 

successes. Quarterly participant evaluations will reflect positive results from the expanded 

range of coordinated services. Deliverable products will include a final report with statistically 

supported findings. Recommendations which delineate methods for replicating successful 

project results will be included in a publishable report. 




Project Title: Lespian, Gay, Bisexual, and Transgender Aging in Place Initiative 



The Los Angeles Gay and Lesbian Community Center 

Senior Services 

1625 N Schrader Boulevard 

Los Angeles, CA 90028-6213 

Contact: 

Karien O’Brien 

Tel. No. (323) 993-7014 

Email: kobrien@lagaycenter.org 


Fiscal 

Year 

Funding 

Amounts 









Total $740,006 


The Los Angeles Gay and Lesbian Center's Seniors Services Department seeks funding for a 

three-year lesbian, gay, bisexual and transgender (LGBT) Aging in Place Initiative, a unique 

intervention providing LGBT seniors with targeted support services, as well as training for 

service providers that assist area seniors as they age in place. The project goal is to ensure 

that LGBT older adults in Los Angeles are treated with dignity and respect as they access a 

comprehensive and coordinated continuum of aging-in-place support services that target 

LGBT seniors. The objectives are to: 1) provide social/recreational programming, support 

services, and educational and intergenerational opportunities that assist LGBT older adults in 

building community and improving social networks, thereby decreasing isolation and 

invisibility; 2) provide short-term case management services, offering LGBT seniors individual 

support and assistance in times of need and crisis; and 3) train local health and human 

service agencies and providers to ensure LGBT older adults receive quality care in 

mainstream institutions. The expected outcomes of this pioneering intervention are: 1) 

increased socialization among and between LGBT older adults: 2) LGBT seniors having 

greater access to LGBT-targeted services; 3) establishment of a central data bank and 

resource clearinghouse for LGBT-friendly resources; 4) LGBT seniors having greater access 

to resources that are LGBT-friendly; and 4) an increase the knowledge and awareness of 

LGBT senior issues and needs among mainstream social service providers. The products of 

this project will be evaluation data that will be useful for local efforts to better serve this 

population; a replicable model with project best practices for serving LGBT seniors, as well as 

a training curriculum, that will be useful to various programs throughout the state and country. 




Project Title: Building A Lifelong Community In South Cobb County 



Atlanta Regional Commission 


40 Courtland Street, N.E. 


Contact: 

Cathie Berger 

Tel. No. (404) 463-3235 

Email: cberger@atlantaregional.com 


Fiscal 

Year 

Funding 

Amounts 









Total $515,868 


The Atlanta Regional Commission, the designated Area Agency on Aging for the ten county 

Atlanta region, is conducting a community capacity building project for aging in place to be 

implemented with support from Cobb County Senior Services and in collaboration with the 

Jewish Federation of Greater Atlanta, Visiting Nurse Health System, and other community 

partners. The goal of Building Lifelong Communities in South Cobb County is to build the 

capacity of a local community in becoming a Lifelong Community where individuals of all 

ages can live throughout their lifetime through comprehensive planning, design, programming 

and community involvement. The objectives are: 1) to improve the design of the built 

environment to promote connectivity, retail and services, and housing stock needed to age in 

place; 2) to implement the NORC (Naturally Occurring Retirement Community) Model to 

enhance the system of long term services and supports that wrap around the built 

environment; and 3) to conduct outreach to involve and train residents to advocate for their 

own needs in the long range process of developing a Lifelong Community. Anticipated 

outcomes are: 1) increased awareness of Lifelong Community Principles among community 

leaders; 2) improved health outcomes for frail elders; 3) greater resident access to services 

and supports that facilitate aging in place; and 4) increased civic engagement among older 

adults in the community. The deliverables will be increased connectivity, retail and services, 

and housing stock for older residents; cross-training and cross-referral protocols among local 

service providers; the development of the South Cobb NORC, and a model program that can 

be replicated regionally and statewide. 




Project Title: Community Innovations for Aging in Place Project 



Coordinating Center for Home and Community Care 

8258 Veterans Highway 

Millersville, MD 201108 

Contact: 

Karen-Ann Lichtenstein 

Tel. No. (410) 987-1048 

Email: kalichtenstein@coordinatingcenter.org 


Fiscal 

Year 

Funding 

Amounts 









Total $859,047 


The Coordinating Center for Home and Community Care is conducting a three year 

Community Innovations for Aging in Place project in collaboration with the Howard County 

Aging and Disability Resource Center (ADRC). The approach integrates innovative case 

management expertise with existing community-based services to sustain independence of 

older individuals. Actualizing aging in place principles, the project goal is to establish a 

partnership between an experienced case management entity and a local ADRC creating a 

model for supporting elderly individuals with specialized health concerns to age in their own 

homes or sites of their choice and avoid costly re-hospitalizations and inappropriate facility 

placement. Objectives of the project are to: 1) provide outreach to identify individuals living 

in a Naturally Occurring Retirement Community (NORC) surrounding area and in danger of 

spending down to Medicaid and nursing home placement; 2) work with Howard County 

General Hospital to implement a comprehensive discharge plan for participants that includes 

follow-up community-based case management; 3) develop comprehensive community living 

plans that encompass the medical, social, educational and recreational supports individuals 

need to age in place, honoring the individual's strengths and choices; 4) provide on-going 

case management ensuring that as the individual's needs change they have access to 

needed care and community supports including community housing alternatives; and 5) 

establish a Community Development Council, comprised primarily of participants. Expected 

outcomes include: 1) hospital readmissions will be significantly reduced; 2) greater use of 

community-based services will be realized; 3) individuals will remain in the community longer; 

and 4) a replicable model of comprehensive care coordination will be implemented. Final 

products will include a final report to include a case management replication model, a refined 

needs assessment, and a plan for sustainability. 




Project Title: Services to Help At-Risk Elders Age in Place (SHARE) 



Boston Medical Center 

Elders Living at Home 

One Boston Medical Center Place 


Contact: 

Ellen Jamieson 

Tel. No. (617) 414-2834 

Email: Ellen.Jamieson@bmc.org 


Fiscal 

Year 

Funding 

Amounts 









Total $560,896 


The Boston Medical Center's Elders Living at Home Program (ELAHP) proposes to provide 

and assess comprehensive services allowing a minimum of 40 low-income, formerly 

homeless older adults who are at risk of recurring homelessness to remain in public housing, 

with maximum independence, improved health and healthcare, and meaningful activities and 

relationships. The approach is to provide comprehensive, individualized, ongoing case 

management targeted to the specific needs of formerly homeless older adults. The goal of 

the project is to implement and evaluate an intervention to assist formerly homeless older 

adults to age in place. The objectives are: 1) to build a support network that is accessible 

and appropriate for formerly homeless older adults; 2) to help these older adults build on their 

individual abilities, interests, and living skills to achieve the highest possible level of selfdetermination; 

and 3) to document and disseminate findings from this intervention that can be 

used to advance services and policies for vulnerable, underserved older adults. The 

expected outcomes of this project are: 1) 95% of older adults will remain in their homes; 2) 

90% of older adults will increase independence, as measured by diminishing reliance on 

services; 3) 80% of older adults will maintain or improve their health status; and 4)80% will 

improve socialization. The products from this project will be data on intensive, individualized 

stabilization services; case studies on both successful and unsuccessful older adults; and a 

document on findings that will be shared with advocates for older adults and used to make 

public policy recommendations at the national, state, and local level. 




Project Title: Caring Communities Resource Centers 

Project Period: 09/2009 – 09/29/2011 


Catholic Charities of Kansas City-St. Joseph, Inc. 

1112 Broadway 

Kansas City, MO 64105 

Contact: 

Michael W. Halteman 

Tel. No. (816) 221-4377 

Email: mhalterman@ccharities.com 


Fiscal 

Year 

Funding 

Amounts 









Total $618,053 


Catholic Charities of Kansas City-St. Joseph is implementing Caring Communities Resource 

Centers for three years in collaboration with senior centers and community partners of health 

and aging expertise. The approach takes health care assistance, social workers, chronic 

disease education and related health activities into senior neighborhood settings. The goal is 

to enhance older adults' ability to live independently and increase healthy behaviors through 

localized access to a continuum of health and social services focused on seniors and their 

caregivers supporting quality of life while aging in place. The objectives include: 1) services 

customized to needs of older adults in low-income, urban and rural neighborhoods; 2) 

outreach activities for awareness of the comprehensive scope of services; 3) intake and 

health screenings to determine health conditions and facilitate care plans for better 

management; 4) intervention, case management, and referrals to health providers; 5) chronic 

disease management workshops and health literacy; 6) mental health services; 7) assisting 

family caregivers to identify their own needs; 8) providing resources to address older 

adult/caregiver circumstances; and 9) respite services. The expected outcomes are: 1) older 

adults demonstrate improvement in healthy aging behaviors and ability to remain 

independent; 2) participants engage in health literacy and screenings; 3) older adults reduce 

reliance on emergency rooms and preventable hospitalization; 4) older adults demonstrate 

better disease self-management; 5) seniors report a greater sense of well-being; 6) 

caregivers demonstrate an increased ability to provide care; and 7) older adults report 

improvement when caregivers share in services. The products are evaluation reports, 

electronic and media articles for publication, and a new replicable model of service. 




Project Title: Seniors Count Coordination Initiative 



Easter Seals New Hampshire 

555 Auburn Street 

Manchester, NH 03103 

Contact: 

Elin Treanor 

Tel. No. (603) 621-3462 

Email: etreanor@eastersealsnh.org 


Fiscal 

Year 

Funding 

Amounts 









Total $598,643 


Easter Seals New Hampshire and Seniors Count are conducting a three year Seniors Count 

Coordination Initiative in collaboration with the Catholic Medical Center, Elliot Senior Health 

Center, Dartmouth-Hitchcock, the Bureau of Elderly & Adult Services, Manchester 

Department of Public Health, and the Aging and Disability Resource Center. The project goal 

is to create and implement a replicable person-centered model that enhances coordination 

between medical services, community living/social services, and caregiver support for frail 

seniors in the Manchester service area. As part of this initiative, the Project Workgroup and 

Advisory Committee's objectives will be to: 1) develop the infrastructure and tools needed to 

make the model successful; 2) hire and train staff; 3) implement the initiative; 4) evaluate the 

effectiveness of the initiative; and 5) disseminate project information. The expected 

outcomes of the project are: 1) seniors and caregivers will indicate satisfaction with the 

initiative; 2) seniors and caregivers will agree that the program helped to prolong the senior's 

ability to age in place; 3) seniors will experience a decrease in revolving-door hospitalization 

and emergency room visits; and 4) caregivers will indicate that the initiative decreased their 

stress level and possibility of burnout. The products from this project will be a final report, 

including evaluation results; a website; articles for publication; an annual symposium; and 

presentations at national venues. 




Project Title: Jewish Family Service of New Mexico's Aging In Place Project 



Jewish Family Service of Greater Albuquerque 

5520 Wyoming Blvd. NE Suite 200 


Contact: 

Michael Gemme 

Tel. No. (505) 291-0332 

Email: Michael@jfsnm.org 


Fiscal 

Year 

Funding 

Amounts 









Total $659,094 


Jewish Family Service New Mexico (JFS) is conducting a three-year Community Innovations 

for Aging in Place (CIAIP) project in collaboration with the New Mexico Aging and Long Term 

Services Department, the Area Agency on Aging and Indian Area Agencies on Aging (AAAs), 

NM Department of Health (DoH), Fort Sumner Community Development Corporation, and 

other service providers. The goal of the project is to implement a culturally diverse, 

innovative, and cost-effective aging in place program for the delivery and coordination of 

community-based health and social services in Native American, rural, urban, and suburban 

communities that supports seniors and their caregivers. The objectives are: 1) develop and 

maintain collaborative partnerships with housing facilities, for and not-for-profit organizations, 

and local, state, and tribal government agencies; 2) develop Partners Advisory Groups 

(PAGs); 3) empower participants to engage in volunteerism; 4) expand the project to include 

HUD-based housing and a Native American pueblo; 5) expand wellness interventions that 

support aging in place; 6) provide transportation activities; 7) promote Aging and Disability 

Resource Center resources and expand access to programs for participants and their 

caregivers; 8) promote long-term project sustainability; 9) evaluate impact of services; and 

10) disseminate project information. The expected outcomes of the project are: 1) a costeffective, 

innovative, and culturally diverse program that increases emotional and physical 

wellbeing for seniors; 2) caregivers are supported through access to respite resources and 

programs; 3) multiple-design evaluations reflecting positive results due to participant-driven 

programming and integrated service provision. The products from the project will be a Brain 

Fitness program; culturally-based training CDs; a marketing toolkit; a final report and 

evaluation results. 




Project Title: Naturally Occurring Retirement Communities Health Plus 



New City Department for the Aging 

2 Lafayette Street Room 729 

New York, NY 10007 

Contact: 

Ishrat Taleb 

Tel. No. (212) 442-0962 

Email: italeb@aging.nyc.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $659,094 


The New York City (NYC) Department for the Aging, in partnership with the United Hospital 

Fund, proposes to broaden the scope of existing Naturally Occurring Retirement 

Communities (NORC) in NYC to improve the health and mental health of residents and guide 

systems change for aging in place models. The goal of the NORC Health Plus program is to 

broaden the scope and guide systems changes to better meet the health and mental health 

needs of older NORC residents. The objectives are to: 1) provide older NORC residents 

with the tools necessary to better manage their health by implementing the evidence-based 

Chronic Disease Self Management Program; 2) empower older residents to better manage 

their mental health by offering Behavioral Activation Therapy; 3) build the capacity of NORCs 

to support service and systems change and assume a broader community role; and 4) 

increase the depth and breadth of NORC residents' participation in the governance and 

operation of the NORC services program. Anticipated outcome are that seniors undergoing 

Behavioral Activation therapy will experience a reduction in depression, improved quality of 

life, increased socialization and participation in activities. Individual outcomes for seniors 

include: 1) improvement in health status and health behavior; 2) greater self efficacy and 

better self-reported health; greater energy and reduced fatigue; 3) fewer social role 

limitations; and 4) better communication with physicians. There will be an increase in the 

number and type of meaningful volunteer opportunities available to NORC seniors. 

Additionally, formal mechanisms for volunteer recruitment, management, and retention will be 

in place and NORC services staff will significantly expand their knowledge base on 

community organizing, transformational leadership, volunteer management, and program 

development and funding resources. Other deliverables include: training manuals, best 

practices manual, and volunteer management tools. 




Project Title: Technical Assistance Provider and Evaluator for the Community 

Innovations in Aging in Place Grantees 



Visiting Nurse Service of New York 

Center for Home Care Policy Research 

1250 Broadway, 20th Floor 


Contact: 

Mia Oberlink 

Tel. No. (212) 609-1537 

Email: mia.oberlink@vnsny.org 

AoA Project Officer: Greg B. Link 

Fiscal 

Year 

Funding 

Amounts 









Total $945,397 


The Center for Home Care Policy and Research (CHCPR) of the Visiting Nurse Service of 

New York (VNSNY) is providing a program of training and technical assistance through a 

collaborative Technical Assistance Grant (TAG) Team approach to the diverse communitybased 

grantees of the Community Innovations for Aging in Place (CIAIP) initiative to assist 

them in their efforts to help older community residents age in place. CHCPR is achieving 

following goals: 1) assist CIAIP grantees in implementing initiatives to help older residents 

age in place; and 2) identify and disseminate "lessons learned" throughout the field and 

beyond. Major objectives are: 1) implement a technical assistance package, including group 

work sessions, individual technical assistance, tools, and resources; 2) convene a National 

Advisory Committee to inform CHCPR activities; 3) conduct an evaluation by tracking key 

indicators critical to aging in place efforts and implement targeted evaluation studies with 

analyses of promising approaches, programs, and services; and 4) synthesize lessons 

learned and translation into actionable steps to inform the field. Expected outcomes are: 1) 

individualized technical assistance meeting the needs of each grantee; 2) grantees 

advancing toward successful aging in place objectives; 3) lessons learned translated into 

actionable steps that inform the field; and 4) additional communities, and nontraditional 

service providers and networks, recognizing the need for aging in place initiatives and using 

CHCPR-produced resources to support their efforts. Products from this program include a 

final report with evaluation results; a website; CIAIP conference proceedings; abstracts and 

teaching materials for presentations at national conferences; tools and resources to support 

the development of aging in place initiatives; "how-to guide"; and 7) articles for publication in 

print and web-based forums. 




Project Title: Growing Healthy Lives Together 



Supportive Older Women’s Network 

4100 Main St., Suite 200 

Philadelphia, PA 19127 

Contact: 

Arlene Segal 

Tel. No. (215) 487-3000 x 11 

Email: asegal@sown.org 


Fiscal 

Year 

Funding 

Amounts 









Total $525,220 


The Supportive Older Women's Network (SOWN) Growing Healthy Lives Together project is 

a comprehensive healthy living program for older adults, predominately women, who are 

aging in place in their homes. The project is targeted to serve a West Philadelphia 

neighborhood that has a very high percentage of minority, poor older adults living alone, with 

chronic multiple health conditions. A major challenge in the identified service area is the lack 

of in-home mental health services. The project is based on a prevention model that is 

inclusive, open to all older residents in the targeted community and accessible - offered in the 

consumer's home/building/community. The Healthy Lives project provides an integrated 

approach to wellness coupling physical and emotional health; it is non-stigmatizing and 

normative and provides on-going support to sustain healthy lifestyle changes. The goal of 

the Healthy Lives project is to improve the physical and emotional well-being of older adults 

by providing a continuum of services to support healthy living. These services include: 

healthy living coaching, healthy living workshops, Healthy Diner lunches, a Fruit First healthy 

snacks program, traveling computer workshops to access health and social services, support 

groups, and volunteer ambassadors. The project looks at addressing barriers to information 

and knowledge, motivational-attitudinal based barriers, and resource-based barriers by 

creating a comprehensive healthy living program that includes education, motivation, 

socialization and resource access. The expected outcomes of this project are: 1) increased 

knowledge of personal well-being and health; 2) improved confidence and self-mastery in 

managing health and well-being; 3) decreased depression, loneliness and social isolation; 

and 4) increased social connectedness. 




Project Title: A Better Way to Live at Home: Education, Resources, and 

Supports for Older Adults 



Family Eldercare 

Housing and Community Services 

2210 Hancock Drive 


Contact: 

Angela Atwood 

Tel. No. (512) 483-3589 

Email: aatwood@familyeldercare.org 


Fiscal 

Year 

Funding 

Amounts 









Total $778,669 


The grantee, Family Eldercare, proposes a three year Community Innovations for Aging in 

Place project in collaboration with the Area Agency on Aging and five other agencies. The 

program will be provided in subsidized housing with high concentrations of low-income older 

adults in three Central Texas communities. The approach is to deliver services through a 

Service Coordinator at each site, provide case management to persons at risk of premature 

institutionalization and provide activities, including evidenced based practices, that impact 

aging in place. The goal of the project is to promote a community in which older adults are 

active and engaged and barriers to aging in place are proactively addressed. The objectives 

are: 1) establish an effective program for promoting aging in place; 2) develop a community 

culture for aging in place; 3) maintain or improve the physical and mental health of older 

adults; 4) increase opportunities for socialization and learning; and 6) reduce the rate at 

which older adults move out. The expected outcomes are: 1) on-site staff and residents 

have increased understanding of the signs that older adults need additional support to remain 

aging in place; 2) reduced fear of falling and improved activity levels among older adults; 3) 

reduced medication problems; 4) improved memory performance; 5) increased older adult 

participation in on site activities and volunteerism; 6) increased knowledge and skills among 

older adults; and 6) increased understanding of the relationship between program activities 

and older adult move out rates. The products are written reports with results and lessons 

learned, Internet posting of information, conference presentations and a toolkit for replicating 

the program. 




Project Title: Houston Aging in Place Innovations 



Neighborhood Centers, Inc. 

Community Based Initiatives 

4500 Bissonnet 

Bellaire, TX 77401 

Contact: 

Chris Pollet 

Tel. No. (713) 669-5250 

Email: cpollet@neighborhood-centers.org 


Fiscal 

Year 

Funding 

Amounts 









Total $973,336 


Neighborhood Centers, guided by the Aging Agenda for Houston and Harris County, will 

implement a three-year Houston Aging in Place Innovations project with the Houston Health 

Department and Area Agency on Aging, the Care for Elders partnership, the YWCA, Interfaith 

Ministries of Greater Houston and Gateway to Care. The project approach is a new role for 

Senior Centers serving naturally occurring retirement communities with a menu of evidencebased 

health promotion programs, case management teams that include certified community 

health workers and elder care field specialists, and neighborhood Elder-Care Action Teams. 

Serving concentrations of low-income, minority older adults in three neighborhoods, the goal 

is that older adults achieve optimal individual levels of functioning and support needed to age 

in place comfortably. The objectives are: 1) neighborhood aging in place assets and gaps 

related to the Aging Agenda are measured; 2) more older adults benefit from evidence-based 

programs and support services provided by Senior Centers, on-site and off-site; 3) older 

adults in case management achieve their individual service plans; and 4) neighborhood 

services to elders improve significantly through more frequent and stronger collaboration. 

Expected outcomes are: 1) older adults, both mobile and homebound, are better prepared 

and supported for a higher quality aging in place experience; 2) senior services providers are 

better connected and coordinated in leveraging resources and efficiently delivering quality 

services; and 3) senior centers are more integrated with other local service providers and 

community development entities, and capable of extending services to other neighborhood 

sites such as churches and senior apartment complexes. The products from this project are 

a final evaluation report and a complete replication report. 




Project Title: Rural Elder Assistance for Care and Health (REACH) 



City of Montpelier 

Department of Planning and Community Development 

39 Main Street 

Montpelier, VT 

Contact: 

Gwendolyn Hallsmith 

Tel. No. (802) 223-9524 

Email: ghallsmith@montpelier-vt.org 


Fiscal 

Year 

Funding 

Amounts 









Total $651,493 


The City of Montpelier is leading a collaborative effort building on the success of the Onion 

River Exchange (ORE), an existing Time Bank, to promote coordination between agencies 

and emerging networks of community-based services. A new social enterprise called 

REACH -- Rural Elder Assistance for Care and Health - will foster health, wellness, and 

resiliency for elders and caregivers, expand services to facilitate aging-in-place, and build 

livable communities for elders of all income levels. The goal is to create a community support 

system for elders in Central Vermont to provide innovative, reliable, and affordable personal, 

health, and social services. Objectives are to: 1) develop REACH social enterprise 

infrastructure enabling stakeholders, community members, elders, and caregivers to build 

networks of giving/receiving; 2) establish innovative REACH social insurance model to 

expand delivery of basic, assisted, and specialized services by rewarding community-based 

contributions; 3) integrate paid and community-based services; 4) create affordable access to 

preventive care for elders; 5) evaluate impacts of REACH; 6) disseminate results and 

lessons learned. The expected outcomes are to: 1) increase vulnerable elders' ability to stay 

in their communities; 2) expand services for elders, especially low-income rural elders, foster 

behaviors that sustain health and independence; 3) increase ratios of community based and 

paid services; 4) improve social, physical and mental wellbeing for elders and caregivers; 5) 

improve community resilience, economic empowerment and livability; and 6) demonstrate 

viability of the REACH social insurance model for aging-in-place in rural settings. Products 

will include replicable social enterprise model to support aging-in-place and promote 

preventive elder care in rural settings; community-based directories of REACH services; and 

customized Community Weaver software for rural settings. 


National Center for Benefits Outreach and Enrollment 

The Administration on Aging (AoA) in conjunction with the Centers for Medicare and Medicaid 

(CMS) awarded support in FY2008 to establish the National Center for Benefits Outreach and 

Enrollment (NCBOE) with funding authorized under the Medicare Improvements for Patients 

and Practitioners Act (MIPPA) to service as resource center to help coordinate and collect 

information about outreach activities of State grants informing older Americans about 

available Federal and State benefits. The Patient Protection and Affordable Care Act 

(PPACA) of 2010 authorized additional benefits for older adults and funding for expansion of 

outreach activities by State Units and Area Agencies on Aging (SUA/AAAs), State Health 

Insurance Counseling and Assistance Programs (SHIPs), and Aging and Disability Resource 

Centers (ADRCs). Additional FY2010 funding for NCBOE was included in the PPACA 

legislation center to help SUA/AAAs, SHIPs and ADRCs report the results of their outreach 

efforts to eligible Medicare adults. 

Additional information about NCBOE and its role in MIPPA can be read on the AoA website: 

http://www.aoa.gov/AoARoot/AoA Programs/Special Projects/Medicare Outreach/index.asp 

x 


Program: National Center for Benefits Outreach and Enrollment 

Grant Number: 90MI002 

Project Title: National Center for Benefits Outreach and Enrollment 



National Council on Aging, Inc. 

1901 L Street, NW – 4 th Floor 


Contact 

Hilary Sohmer Dalin 

Tel. (202) 479-6626 

Email: hilary.dalin@ncoa.org 

AoA Project Officer: Katherine J. Glendening 


Fiscal 

Year 

Funding 

Amounts 









Total $5,000,000 

The National Center for Benefits Outreach and Enrollment (NCBOE) established in 2008 at 

the National Council on Aging serves as a central coordinator of national, state and local 

efforts to enroll low-income seniors and younger adults with disabilities into benefits in a 

person-centered, cost-efficient manner. Under this grant NCBOE will continue to work with 

its partners to increase the coordination of benefits and participation of seniors and younger 

adults with disabilities in benefits programs. Project objectives are to: 1) broaden the 

national network of Benefits Enrollments Centers (BECs); 2) increase the usability of current 

benefits screening and enrollment systems; 3) improve benefits coordination and 

collaboration; 4) promote the use of cost-effective outreach and enrollment strategies in the 

aging and disability provider networks; 5) provide training and technical assistance (TA) 

regarding cost-effective strategies, promising practices and other topics related to benefits 

outreach and enrollment; 6) measure and report on the performance of MIPPA-funded 

agencies; 7) disseminate results to diverse audiences; and 8) manage the NCBOE efficiently 

and with attention to multiple audiences. The expected outcomes are: 1) expansion of the 

BEC network; 2) increased number of consumers receiving benefits information and 

assistance; 3) increased use of web-based screening and enrollment tools; and 4) increased 

number of professionals receiving training and TA on benefits-related issues. In addition to 

periodic and final reports, other products produced under this grant include Issue Briefs, case 

studies, articles and e-newsletters. 


Aging Network Improvements 

The Administration on Aging (AoA) has periodically since 1973 relied upon the support 

and cooperation of national organizations representing agencies administering programs 

supported under the Older Americans Act (OAA) to increase the capacity of the Aging 

Network not only to conduct OAA programs effectively and efficiently, but to integrate 

and coordinate aging service programs and activities supported by States and other 

Federal Agencies. 

In FY2010 AoA funded the second year of a project to train the leadership of area 

agencies on aging and tribal governments receiving OAA Title VI support. It also held a 

grant competition for support of a project to strengthen the leadership and management 

of State Units on Aging (SUA) an emphasis on analysis and development of standards 

for performance measurement, and evaluations of SUA progress in priority areas of 

systems change in managing home an community-based service systems. 


Program: Aging Network Improvements 


Project Title: Project to Increase Capacity of Area Agencies on Aging/Title VI 

Aging Programs by Providing Tools and Resources 



National Association of Area Agencies on Aging 

1730 Rhode Island Avenue, NW Suite 1200 


Contact: 

Helen Eltzeroth 

Tel. No. (202) 872-0888 

Email: heltzeroth@n4a.org 


Fiscal 

Year 

Funding 

Amounts 









Total $894,227 


The National Association of Area Agencies on Aging (N4A) is partnering with Scripps 

Gerontology Center to increase the management and leadership capacities of Area Agencies 

on Aging (AAAs) and Title VI aging programs and broaden their role in the delivery of 

community-based services and supports to better address the needs of older adults and their 

caregivers. The goal of the project is to increase the capacity of AAAs and Title VI Native 

American aging programs to enhance management practices and methodologies; leadership; 

and their role in the delivery of community-based services and supports. Project objectives 

include: 1) expand the knowledge base of AAA and Title VI programs regarding operations 

and trends, management, program development and services that promote continuous 

quality improvement; 2) provide training and technical assistance to AAA and Title VI staff on 

trends, tools, strategies and techniques to expand and enhance their operations; and 3) 

enhance and support the knowledge base and leadership of AAA and Title VI governance 

boards on the roles and responsibilities of the Aging Network to respond strategically to the 

needs of older adults and caregivers. Project outcomes are that AAA and Title VI programs 

will provide state-of-the-art management and performance-based programs and systems that 

enable older adults to age successfully at home and in the community for as long as possible. 

The project will disseminate findings and reports to the AAA and Title VI community, as well 

as to the aging field. N4A will market the dissemination of the project materials through 

promotion to AAAs, Title VI programs, AoA, State Units on Aging and the broader aging field. 


Program: Aging Network Improvements 


Project Title: Strengthening the Aging Network 



National Association of States United for Aging and Disability 

1201 15 th Street, NW Suite 350 


Contact 

Mike Cheek 

Tel. No. (202) 898-2578 

Email: mcheek@nasuad.org 

AoA Project Officer: Greg Case 


Fiscal 

Year 

Funding 

Amounts 









Total $500,000 

The National Association of States United for Aging and Disability (NASUAD) proposes to 

administer this grant in collaboration with the Administration on Aging (AoA), the National 

Association of Area Agencies on Aging (n4a), and other partners. The project’s goal is to 

increase the capacity of State Units on Aging across the country to play strong leadership 

roles in the development and implementation of modernized systems of long term services 

and supports (LTSS). The objectives are: 1) to design and implement an intensive advanced 

flexible training system for SUA directors, including, but not limited to, new directors and their 

senior staffs; 2) to gather information about current performance standards used by states to 

measure the impact of their LTSS systems; and 3) to design and conduct an evaluation tool 

that will assess SUA’s progress in key areas of systems change. The expected outcomes 

are: 1) increased number of trained SUA directors and senior staffs prepared to administer 

Older Americans Act (OAA) and Medicaid HCBS waiver programs; 2) increased number of 

knowledgeable SUA directors and senior staffs capable of expanding their agencies’ capacity 

to play strong leadership roles in the development and implementation of modernized LTSS 

systems in their states; 3) improved awareness of SUA directors about performance 

standards that states are using to measure the impact of their LTSS systems; and 4) the 

ability to evaluate states ’ progress in key areas of systems change. NASUAD will produce 

as products an advanced, flexible training system for SUA leadership; performance standards 

for measuring the impact of LTSS systems; evaluation tool to assess SUA’s progress in key 

areas of systems change; website resources; newsletter articles; whitepaper; conference 

presentations and abstracts; and a final report. 


Lesbian, Gay, Bisexual and Transexual Elders Resource Center 

The Administration on Aging held its first discretionary grants competition in FY2010 for Title 

IV, Older Americans Act support of a national resource center designed to assist national, 

state and local organizations in serving lesbian, gay, bisexual and transgender (LGBT) 

elders. The funding announcement sought proposals focused on a primary mission of 

serving LGBT individuals with the information and technical assistance they need to maintain 

independence as they age. Applicants addressed three objectives: 1) education of 

mainstream aging services organizations about the existence and special needs of LGBT 

elders; 2) sensitization among LGBT organizations about the existence and special needs of 

older adults; and 3) education of LGBT individuals about the importance of planning ahead 

for future long-term care needs. 


Program: Lesbian, Gay, Bisexual and Transexual Elders Resource Center 

Grant Number: 90LG0001 

Project Title: LGBT Elders Resource Center 


Grantee 

Senior Action in a Gay Environment (SAGE) 

305 Seventh Avenue, 6th Floor 



Year Amount 


Contact: 

Scott French 

Tel. (212) 741-2247 

Email: sfrench@sageusa.org 



Total $300,000 

SAGE - the country’s oldest and largest organization serving lesbian, gay, bisexual and 

transgender (LGBT) older adults - and a partnership of 10 organizations with expertise in 

mainstream aging, LGBT aging, culture change and program evaluation will create the 

Technical Assistance Resource Center: Promoting Appropriate Long-Term Care Supports for 

LGBT Elders (Resource Center). In conjunction with a diverse advisory council and private 

funding organizations, SAGE and its partners seek to empower and support: (1 mainstream 

aging providers; 2) LGBT organizations; and 3) LGBT older adults to ensure that LGBT 

elders have necessary services and supports to successfully age in community. Progress 

will be measured by improvements in the ability of aging services providers to respectfully 

and appropriately serve LGBT clients, expansion in the number of available LGBT-sensitive 

and LGBT-specific aging programs, and an increase in the number of LGBT older adults who 

feel better prepared to address and plan for their own long-term care needs. The Resource 

Center will develop: 1) a comprehensive, interactive, web-based clearinghouse with 

resources useful to all three audiences; 2) a train-the-trainer curriculum and national LGBT 

aging training corps; 3) in-person trainings and webinars; 4) best practice publications; 5) 

consumer educational materials and campaigns; 6) a listserv to provide professionals 

ongoing technical assistance and support; 7) dedicated phone and email technical assistance 

portals; and 8) a range of social media vehicles to entice users to remain in contact with the 

Resource Center and grow along with it. In addition, careful collection and analysis of user 

data will enable the Resource Center to meet emerging and evolving needs, close knowledge 

gaps, and identify issues to be addressed by policymakers and relevant professionals. 

Special outreach and attention will be paid to low-income, rural, transgender, limited Englishspeaking 

LGBT elders and LGBT elders of color. 


National Center on Elder Abuse 

The National Center on Elder Abuse (NCEA) was first funded by the Administration on Aging 

in 1988 with a grant to the Public Welfare Association. Over the years, and with expansion of 

authority for its support through the 1992 Older Americans Act Amendments, its activities as 

a national resource center for prevention of elder abuse have grown. The Center currently 

functions as a collaboration of three equal partners, the University of Delaware, the National 

Adult Protective Service Association and the National Committee for the Prevention of Elder 

Abuse, 

The goals of NCEA are to develop and disseminate information for professionals to increase 

elder abuse, neglect, and exploitation; to identify, report and guide programs that protect 

older people; to provide tools to increase professional ability of those with daily access to 

seniors to identify, address, and prevent elder abuse, neglect, and exploitation; and to 

promote systems change through development of programs, models, and initiatives that 

measurably decrease elder abuse, neglect, and exploitation incidence. 

Information about NCEA may be found on the Administration on Aging website: 

http://www.ncea.aoa.gov/ncearoot/Main Site/index.aspx 


Program: National Center for Elder Abuse 


Project Title: National Center for Elder Abuse 



National Adult Protective Services Association 

920 Spring St Ste 1200 

Springfield , IL 62704 

Contact: 

Kathleen Quinn 

Tel. No. (217) 523-4431 

Email: kathleen.quinn@apsnetwork.org 

AoA Project Officer: Stephanie D. Whittier Eliason 

Fiscal 

Year 

Funding 

Amounts 









Total $782,533 


National Center on Elder Abuse (NCEA) is an equal partner, multi-disciplinary consortium 

with expertise in elder abuse, neglect, and exploitation. The National Adult Protective 

Services Association is executing a 4-year program as a collaborator in the NCEA, and is 

undertaking the following activities to promote the above goals: 1) conduct a national needs 

assessment to identify both the elder abuse training needs of, and currently available training 

for, targeted professionals; 2) develop a feasible, long range strategic plan to address gaps 

identified in the needs assessment; 3) continue to maintain and expand the national elder 

abuse/APS training library; 4) continue to develop and disseminate training materials for 

personnel engaged in preventing, identifying, and treating elder abuse, neglect, and 

exploitation; 5) conduct four annual, national webcasts on elder abuse and Adult Protective 

Services to disseminate information for targeted professions; and (6) annually prepare and 

distribute an annotated bibliography of recent elder abuse research. Expected outcomes are: 

1) timely, high quality information to support state and local capacity building and innovation; 

2) increased professionalization of adult protection and elder abuse service networks; and 3) 

increased knowledge of the extent and causes of elder abuse and skills and practices for 

prevention. 







National Committee for the Prevention of Elder Abuse 

1612 K Street NW Ste 400 


Contact: 

Pamela B. Teaster 

Tel. No. (202) 682-4140 

Email: pteaster@email.uky.edu 


Fiscal 

Year 

Funding 

Amounts 









Total $1,200,000 


National Center on Elder Abuse (NCEA) is an equal partner, multi-disciplinary consortium 

with expertise in elder abuse, neglect, and exploitation. In support of the NCEA goals, the 

National Committee for the Prevention of Elder Abuse is executing a 4-year program as a 

collaborator in the NCEA and undertake the following activities to encourage and enhance 

development of comprehensive elder justice systems: 1) award mini-grants of approximately 

$10,000 each year to support the creation and promote the sustainability of multidisciplinary 

local and state elder abuse networks; 2) provide technical assistance to states and AAAs to 

promote the widespread development, implementation, and sustainability of new or existing 

local and state elder abuse networks; 3) maintain and augment the Promising Practices 

Clearinghouse; and 4) develop analyses of state statutory issues and track federal laws that 

impact elder abuse detection, intervention, and prevention and disseminate that information. 

The expected outcomes are: 1) timely, high quality information to support state and local 

capacity building and innovation; 2) increased professionalization of adult protection and 

elder abuse service networks; and 3) increased knowledge of the extent and causes of elder 

abuse and skills and practices for prevention. 







University of Delaware 

Center for Community Research and Service 

210 Hullihen Hall 

Newark, DE 19716 

Contact: 

Judith Trefsger 

Tel. No. (302) 831-2828 

Email: trefsger@udel.edu 


Fiscal 

Year 

Funding 

Amounts 









Total $879,998 


The University of Delaware (UD) is an equal partner in the Delaware National Center on 

Elder Abuse (NCEA), a multi-disciplinary consortium with expertise in elder abuse, neglect, 

and exploitation. As a four year NCEA program collaborator, UD supports the its goals with 

an emphasis on increasing national awareness of elder abuse and NCEA resources and 

services, and to: 1) promote public awareness materials; 2) create a strategic social 

marketing plan and implement select elements; 3) develop and disseminate products to 

enhance public and professional response to elder mistreatment; 4) foster 

coordination/communication among entities addressing elder mistreatment; 5) provide 

effective managerial support to NCEA. Anticipated outcomes are: 1) increased national 

awareness of elder abuse as a social problem requiring action; 2) enhanced awareness/use 

of NCEA resources/ services; 3) improved prevention and intervention strategies by 

practitioner use of NCEA resources/services; and 4) expanded capacity to respond to needs 

of stakeholders through efficient and effectively managed NCEA. Products include an online 

user-searchable, public awareness resource inventory; a strategic social marketing blueprint; 

customizable fact sheets, issue briefs, and educational/outreach materials; elder abuse 

listserv maintenance; monthly e-newsletters; and a self-service article/research database 


National Long Term Care Ombudsman Resource Center 

The National Long Term Care Ombudsman Resource Center (Center) was established in 

1988 with an Administration on Aging (AoA) grant awarded to the National Association of 

State Units on Aging (now the National Association of States United for Aging and 

Disabilities) in collaboration with the National Citizen’s Coalition for Nursing Home Reform 

(now the National Consumer Voice for Quality Long-Term Care). The need for the Center 

became evident after substantive changes were made in the 1988 Older Americans Act 

Amendments increasing the responsibilities and authority of State ombudsman programs. 

The Ombudsman Program began in 1976 following the success of demonstrations first 

funded in 1972 and transferred to AoA in 1973. 

The statewide ombudsman programs are federally funded under Titles III and VII of the Older 

Americans Act and other federal, state and local sources. Long-Term Care Ombudsmen are 

advocates for residents of nursing homes, board and care homes, assisted living facilities 

and similar adult care facilities and work to resolve problems of individual residents through 

mediation and if necessary referral to State authorities. A primary goal of the Ombudsman 

Program is to bring about changes at the local, state and national levels that will improve 

residents’ care and quality of life. 

Information about the Center and the Long Term Care Ombudsman Program is found on the 

AoA website: 

http://www.aoa.gov/AoARoot/AoA Programs/Elder Rights/Ombudsman/index.aspx 


Program: National Long-Term Care Ombudsman Resource Center 


Project Title: National Long-Term Care Ombudsman Resource Center 



National Consumer Voice for Quality Long-Term Care 

1828 L Street, NW, Suite 801 


Contact: 

Lori Smetanka 

Tel. No. (202) 332-2275 

Email: lsmetanka@theconsumervoice.org 

AoA Project Officer: Nichlas Fox 

Fiscal 

Year 

Funding 

Amounts 









Total $4,381,444 


The goal of this cooperative agreement between AoA and the National Consumer Voice for 

Quality Long-Term Care (formerly the National Citizens' Coalition for Nursing Home Reform) 

is to equip the long-term care ombudsmen to carry out their responsibilities under the Older 

Americans Act. Responsibilities are to: 1) address the problems and complaints of residents 

of long-term care facilities; and 2) represent residents’ needs and interests. To attain these 

goals, the Center provides support, training and technical assistance to the ombudsman 

network that daily responds to requests for assistance from facility residents, their families 

and the public. The five objectives are: 1) to direct training and training materials to enhance 

ombudsman skills; 2) to develop specific products and dialogue forums; 3) to conduct daily 

technical assistance, and provide information and referral services on program management, 

program promotion, training, and pertinent national and state long-term care issues; 4) to 

promote the ombudsman program; and 5) to collaborate on efforts to strengthen ombudsman 

involvement in state and national initiatives. The anticipated outcomes include: 1) transmittal 

of current and accurate information to ombudsmen and State Agencies on Aging directors, to 

improve their state training, management, program promotion and advocacy functions; 2) and 

full utilization of the Center's technical assistance and products. Products include a final 

report; training materials; data base enhancements; and conference materials. 


Pension Counseling and Information Program 

Since 1993, the Administration on Aging (AoA) has funded the Pension Counseling and 

Information Program (the Program) to help individuals understand and exercise their pension 

rights. Originally a demonstration project, pension counseling became a permanent program 

under Title II of the Older Americans Act (OAA) in 2000 and consists of multiple counseling 

projects and a single national technical assistance project. In FY 2001 and 2002, AoA shifted 

its funding focus from local and statewide projects to multi-state, regional projects in order to 

move the Program toward nationwide coverage. AoA currently funds six regional counseling 

projects that serve 29 states. AoA also funds a national technical assistance and resource 

center that provides the counseling projects with legal training, case consultation and 

operational support. 

Additional information about the Pension Counseling and Information Program may be read 

on the AoA website: 

http://www.aoa.gov/AoARoot/AoA Programs/Elder Rights/Pension Counseling/index.aspx 


Pension Counseling and Information Projects 

In FY2010 AoA held a competition for new three year projects and awarded six (6) grants to 

organizations having a proven record of advising and representing individuals who have been 

denied employer or union-sponsored retirement income benefits. The counseling and 

information projects provide individuals who reside, have worked in, or have some other 

pension or employer connection to the regional service area with drafting administrative 

pension claims and appeals, providing representation and support through administrative 

proceedings; identifying and pursuing pension benefits from clients’ prior employers; and 

answering basic questions about rights and remedies under all public and private pension 

systems throughout their service region regardless of age or income, though targeting 

outreach efforts to those in greatest need. 


Program: Pension Information Counseling Projects 

Grant Number: 90PC0006 

Project Title: Western States Pension Assistance Project 



Legal Services of Northern California 

Senior Legal Hotline 

517 12th Street 


Contact: 

David L. Mandel 

Tel. (916) 551-2142 

Email: dmandel@lsnc.net 

AoA Project Officer: Valerie Soroka 


Year Amount 


Total $200,000 


Legal Services of Northern California will continue provision of comprehensive regional 

pension counseling and information services throughout Arizona, California, Hawaii, and 

Nevada. The Western States Pension Assistance Project will continue its successful colocation 

with the statewide Senior Legal Hotline, while maintaining its distinct identity with 

separate outreach and dedicated full-time staff that possesses expertise in pensions and 

retirement benefits. The target population is vulnerable seniors; including disadvantaged, 

hard-to-reach, and limited-English speaking populations (the region’s four states are among 

the most diverse in the nation). Expected project outcomes include: 1) greater awareness of 

pension assistance; 2) increased access to pension plan information and benefits; and , 3) 

promotion of financial security, increased choice, and greater independence in retirement. In 

addition to counseling and case assistance, objectives include: 1) developing a network of 

experts to consult on cases and accept referrals when more help is needed; 2) conducting 

outreach through the aging and legal services networks, unions, government agencies, 

private bar and media, targeting especially those in greatest need and those most likely to 

benefit from pension help; and 3) building ties with partners in other states to create an 

effective regional program. Products will include lessons learned, an expanded website, 

press releases, conference materials and other outreach products, and training materials. 




Project Title: New England Pension Assistance Project 



University of Massachusetts Boston 

Gerontology Institute 

100 Morrissey Blvd 

Boston, MA 02125-3393 

Contact: 

Ellen A. Bruce 

Tel. (617) 287-7315 

Email: ellen.bruce@umb.edu 



Year Amount 


Total $200,000 


The Gerontology Institute of the University of Massachusetts Boston will continue operation 

of the New England Pension Assistance Project, with the goal of increasing workers’ and 

retirees’ knowledge of and access to retirement benefits through pension counseling. The 

target population is older workers and retirees in the six New England states (Connecticut, 

Massachusetts, Maine, New Hampshire, Rhode Island, and Vermont), with particular 

outreach to women, low-income and minority elders, and seniors with limited English 

proficiency. The project objectives are to: 1) provide individual pension counseling in the six 

New England states; 2) conduct outreach to older workers, retirees, and the community in 

New England to maximize appropriate client intake and inform them about different types of 

pensions and individual pension rights; and 3) maintain program consistency with AoA 

Pension Counseling programs through staff training, data collection, and shared information 

on recurring problems faced by workers. Objectives will be accomplished through a program 

of individual counseling and referrals, case investigation, legal research, community 

education, and outreach. The expected outcomes are: 1) to maximize workers’ and retirees’ 

income, and 2) to increase awareness of pension rights, issues, and problems among clients 

and the general population. Products will include semi-annual newsletters; evaluation 

methodology and results (as part of the final report); and an enhanced website. 




Project Title: Mid-America Pension Rights Project 



Elder Law of Michigan, Inc. 

3815 W. St. Joseph St., Suite C-200 

Lansing, MI 48917-3682 


Year Amount 


Contact: 

Katherine B. White 

Tel. (517) 853-2375 

Email: kwhite@elderlawofmi.org 



Total $200,000 

The goal of the Mid-America Pension Rights Project is to operate a regional pension 

counseling and information service to 600-800 individuals per year in Michigan, Ohio, 

Pennsylvania, Kentucky, and Tennessee, with gradual expansion into Indiana. The target 

population includes vulnerable seniors (those with limited English proficiency, profound health 

problems/disabilities or caregiving responsibilities), low-income seniors, those without internet 

access, and seniors in rural areas. The approach utilizes specialized, toll-free telephone 

service with quick call responses from attorneys who are pension specialists; a project 

website; and pension-specific, targeted outreach. Expected outcomes include: 1) 

improvement of the financial situation and security of retirees and their spouses; 2) 

enhancements in the understanding of pension benefits, rights and options; and 3) increases 

in the availability of, and access to, high quality pension counseling and information in 

Indiana. In addition to the provision of consistent and reliable pension counseling and 

information services, a major objective is to conduct regional outreach activities to reach all 

area pensioners including those who are in rural areas, have limited English proficiency, or 

profound health problems/disabilities. Products to be created include: a revised project 

outcome survey; a report measuring the change in economic security for pensioners 

receiving monetary recoveries; and new electronic outreach materials designed to 

complement existing regional and national marketing materials. 

. 




Project Title: Upper Midwest Pension Rights Project 



Metropolitan Area Agency on Aging, Inc 

2365 North McKnight Road 

North St. Paul, MN 55109 


Year Amount 


Contact: 

David Bonello 

Tel. (651) 251-5766 

Email: dbonello@tcaging.org 



Total $200,000 

The Metropolitan Area Agency on Aging of North St. Paul, Minnesota, will partner with Iowa 

Legal Aid, the Coalition of Wisconsin Aging Groups, Legal Services of North Dakota, and the 

University of South Dakota Elder Law Forum to provide quality, comprehensive pension 

counseling, information, and referral through a coordinated regional service delivery model to 

Minnesota, Wisconsin, Iowa, North Dakota and South Dakota. The target population is older 

workers and retirees, with special emphasis upon rural communities, labor groups, women’s 

groups, and limited English-speaking communities. Project objectives are to 1) deliver 

pension counseling services, including assisting with survivor benefits, drafting claims and 

appeals, and conducting lost pension searches; 2) conduct outreach activities including 

intake and referral through partnerships and targeted initiatives; and 3) maintain and enhance 

operational efficiency by identifying, sharing and implementing effective pension counseling 

practices, and collecting and reporting on project data. Expected project outcomes include: 

1) an increase in overall economic self-sufficiency of retirees served; 2) heightened consumer 

awareness of pension counseling, information, 3) referral services; restoration of legal rights 

and pension benefits to participants who often can least afford to go without retirement 

income; and 4) increased efficiencies and improved project outcome data. Expected 

products include articles for publication, outreach materials, and web pages. 




Project Title: Mid-Atlantic Pension Counseling Project 



South Brooklyn Legal Services, Inc. 

Benefits and Employment Unit 

105 Court Street 

Brooklyn, NY 11201-5658 

Contact: 

Gary Stone 

Tel. (718) 237-5500 

Email: gstone@sbls.org 



Year Amount 


Total $200,000 


South Brooklyn Legal Services will to continue operation of the Mid-Atlantic Pension 

Counseling Project, with the goal of providing pension counseling and information for the 

New York and New Jersey region. The target population is retired workers and their 

dependents, with particular emphasis upon low-income, isolated, frail, and homebound 

clients and non-English speaking communities. Project objectives include: 1) resolving each 

caller’s pension problem by providing specialized services, ranging from information to direct 

counseling and assistance; 2) reaching people throughout the region; and 3) collecting 

information about project services, to be shared with other regional projects. The project will 

reach out to retired workers and their dependents, and target isolated and homebound clients 

by providing telephone access, while taking advantage of newspapers and other widelydisseminated 

media to increase awareness of the availability of project services. Non- 

English speaking clients will be served by using bilingual staff and on-demand translators. 

The expected outcomes are that clients will receive specialized and individualized expert 

assistance and, as a consequence, enjoy increased financial security as well as increased 

capacity to make informed decisions concerning their retirement income. The major products 

from this project will be three years of data concerning clients and the services they need. 




Project Title: South Central Pension Rights Project 



Texas Legal Services Center, Inc. 

815 Brazos St., Suite. 1100 

Austin, TX 78701-2509 


Year Amount 


Contact: 

Roger Curme 

Tel. (512) 477-6000 142 

Email: rcurme@tlsc.org 



Total $200,000 

Texas Legal Services Center will to continue providing pension counseling and information 

services throughout Arkansas, Louisiana, Missouri, Oklahoma, and Texas and to establish 

services in New Mexico, through the South Central Pension Rights Project. The overall goal 

of the project is to meet the increased demands for outreach, counseling, referral and 

information dissemination created by the challenges of the current economic environment, in 

an effort to protect financial security and foster independence in retirement. The target 

population is retired workers and their dependents, with particular emphasis upon 

disadvantaged, non-English speaking, rural, and other hard-to-reach populations. Objectives 

include: 1) regional service delivery of counseling and information services on the exclusive 

subject matter of pensions; 2) provision of regional intake and a referral network; 3) conduct 

of project-specific outreach; tracking of outreach activity and outcomes; 4) programmatic 

consistency in staffing, legal training and resources, data collection and reporting, and 5) 

shared learning. Expected outcomes include: 1) a positive change in the degree of customer 

satisfaction; 2) promotion of financial security and independence among retirees; and 3) 

overall improvement in seniors’ financial, emotional, physical, or mental well-being. The 

major products from this project will include publications regarding state and local 

government pension plans within the region, an enhanced website, and an operations 

manual. 


National Pension Assistance Resource Center 

AoA funds a Technical Resource and Assistance Center (the Center) specifically to deliver 

legal training and case consultation, as well as operational support and coordination, to the 

pension counseling project network established in 1991. Currently six organizations funded 

by AoA (See Pension Counseling and Information Projects) offer counseling services on a 

regional basis. Until funding is available to support a nationwide network, the Center is 

further called upon to assist individuals living in areas not currently served by an AoA 

Pension Counseling Project by maintaining a nationwide dataset of pension information and 

assistance resources, including government agencies, legal and aging services providers, 

legal hotlines, lawyer referral services, and the array of community services and private 

professionals that provide some level of pension assistance. The Center also provides 

necessary technical assistance to this expanded network of pension assistance resources. In 

addition, a critical nationwide outreach function is provided by the Center, ensuring that both 

individuals in need and key service provider stakeholders know about all available pension 

assistance resources. 

In FY2010 AoA held a grant competition for a new three year cooperative agreement to 

support the Center open to organizations with a proven record of advising and representing 

individuals who have been denied employer or union-sponsored pension and retirement 

savings plan benefits; the capacity to provide services under the Program on a national basis; 

and a well-established, positive reputation in their respective professional communities. 

Additional information about the Pension Counseling and Information Technical Assistance 

Resource Center and a link to its site may be found on the AoA website: 

http://www.aoa.gov/AoARoot/AoA Programs/Elder Rights/Pension Counseling/index.aspx 


Program: Pension Counseling and Assistance 

Grant Number: 90PX0001 

Project Title: National Pension Assistance Resource Center 



Pension Rights Center 

1350 Connecticut Avenue, N.W., Suite 206 



Year Amount 


Contact: 

John Hotz 

Tel. (202) 296-3776 

Email: jhotz@pensionrights.org 



Total $421,253 

The Pension Rights Center will continue management and operation of a National Pension 

Assistance Resource Center to support the Administration on Aging’s (AoA) Pension 

Counseling and Information Projects and other pension assistance providers, with the goal of 

ensuring that older Americans receive the retirement benefits they have earned. The target 

population is older workers and retirees nationwide, with a special focus on hard-to-reach and 

traditionally disadvantaged groups, including minorities, women, and non-English speaking 

populations. The major project objectives are to: 1) design and deliver high-quality pension 

law training and supporting educational materials, and to provide ongoing technical 

assistance and legal back-up services to AoA’s regional pension counseling projects and the 

extended community of legal services providers willing to assist; 2) maintain and publicize 

PensionHelp America, a nationwide Internet-based pension information and referral service; 

and 3) promote and facilitate the identification, sharing and implementation of best practices 

among the AoA pension counseling projects, and to support the uniform collection and 

reporting of reliable program-wide outcome data. Expected outcomes include enhanced 

capabilities of AoA’ s Pension Counseling and Information projects, resulting in increased 

independence and financial security of older Americans. Products will include training 

curricula; development and coordination of a three-day national training conference; 

customized field-based training; maintenance of a pension counseling listserv, Pension 

Counseling.Net and PensionHelp America website; publications, testimony, and brochures; 

and enhancement of the Pension Assistance Information Database online data collection 

tool. 


Model Approaches to Statewide Legal Assistance 

The Administration on Aging (AoA) maintains support for state leadership efforts to develop 

and maintain effective, high quality, high impact, and targeted legal service delivery systems 

that maximize the impact of limited legal resources on older adults in greatest need. In 

FY2010 AoA held a cooperative agreement project grant competition to support seven (7) 

projects in eligible states to develop approaches that promote state leadership and 

sustainability beyond the AoA funding period. AoA awarded second year continuation grants 

in FY2010 to eleven (11) projects funded in FY2009. Descriptions of the eighteen (18) State 

grants are included in this compendium 

The goal of Model Approaches is to protect and enhance essential rights and benefits of 

older persons in states across the country by utilizing the leadership of the State Legal 

Assistance Developer and key project partners to create and maintain coordinated, well 

integrated, and cost effective statewide legal service delivery systems. Such systems should 

ultimately include: integration of a low-cost senior legal helpline with IIIB legal services and 

other low-cost mechanisms to achieve cost-efficiency and maximum impact from limited legal 

resources as well as effectively target scarce resources to older persons in greatest social or 

economic need. Applicants were asked to focus on the most critical legal issues confronting 

target populations and integrate them into the legal service delivery system within the broad 

aging service network. 

Additional information about AoA’s support of the Legal Assistance Program may be found on 

AoA’s website: 

http://www.aoa.gov/AoARoot/AoA Programs/Elder Rights/Legal/index.aspx 


Program: Senior Legal Services-Model Approaches 

Grant Number: 90SL0012 

Project Title: Alaska Statewide Model Approach to Statewide Legal Assistance 

Systems 



Alaska Legal Services Corporation 

1648 Cushman Street, Suite 300 

Fairbanks, AK 99701 


Year Amount 


Contact: 

Andy Harrington 

Tel. (907) 452-5181 

Email: aharrington@alsc-law.org 

AoA Project Officer: Omar Valverde 

Total $100,000 


Alaska Legal Services Corporation (ALSC) will partner with the Alaska Department of Health 

and Social Services, the Aging and Disabilities Resource Center, the Division of Senior and 

Disabilities Services, and the Alaska Commission on Aging with the goal of increasing overall 

access to legal services for elders within the state of Alaska, particularly for those in greatest 

social and economic need. Over a three year time frame ALSC will: 1) plan and implement a 

manageable, and feasible seniors legal needs assessment; 2) develop a project plan based 

upon the results of the assessment; 3) integrate and expand statewide resources by 

implementing low-tech tools to increase senior access to legal resources; 4) assess at least 

12 months of data to determine program effectiveness; 5) determine overall impact and future 

sustainability for the project; and 6) disseminate project information. Anticipated outcomes 

are: 1) increased community awareness about the availability of senior legal services; 2) 

increased access to a potential statewide Senior Legal Help-line; 3) easily accessible lowtech 

legal resources for seniors; and 4) an increased level of access to legal services for 

seniors. 




Project Title: Model Approaches to Statewide legal Assistance 



Legal Services of Northern California 

517 12TH Street 


Contact: 

David Mandel 

Tel. (916) 551-2142 

Email: dmandel@lsnc.net 

AoA Project Officer: Valerie B. Soroka 

Fiscal 

Year 

Funding 

Amounts 









Total $200,000 


California's Senior Legal Hotline (SLH), the Department of Aging (CDA), and the Legal Aid 

Association of California (LAAC) is continuing a three-year partnership to better meet the 

legal needs of many more seniors, targeting the most needy among the state's huge, diverse 

population and reducing serious disparities in the existing availability of legal help. The 

project goal is to increase the availability of low-cost, high-quality legal assistance to seniors 

through improved coordination among the hotline, local senior legal services providers, the 

Dept. of Aging, and others. Objectives include conducting assessments of seniors’ legal 

needs and gaps in the existing delivery system; setting policies that will improve efficiency 

through service coordination and reduced duplication; increasing volunteer participation, 

focusing especially on the State Bar’s Pro Bono Practice Program; harnessing the aging and 

legal services networks and media for targeted outreach; establishing a permanent body of 

stakeholders to provide feedback and advocate for expansion of senior legal services; and 

striving to increase support for sustainability and growth of the hotline and senior legal 

services providers. Proposed project outcomes include: 1) better access to senior legal 

services; 2) more pro bono volunteers; and 3) greater efficiency and better results through 

increased coordination and collaboration. Products will include reports from the needs and 

gap assessments, updated standards and reporting protocols, agreements on provider 

coordination, client self-help materials, advocate resources, and outreach plan and materials. 




Project Title: Delaware Legal Hotline Grant 




1901 N. DuPont Highway 



Year Amount 


Contact: 

Linda Heller 

Tel. (302) 255-9390 

Email: Linda.Heller@state.de.us 



Total $100,000 

The Delaware Model Approaches project creates a partnership between the Division of 

Services for Aging and Adults with Physical Disabilities (DSAAPD), the Community Legal Aid 

Society, Inc. and the Delaware Helpline to create a comprehensive, well integrated, cost 

effective, and targeted legal service delivery system. The partners, under the leadership of 

the state Legal Assistance Developer (LAD), will develop and implement the Legal 

Assistance Hotline Program (LAHP) that will serve as a single point of entry into legal 

services for all of Delaware’s seniors and their caregivers. Its objectives are to: 1) target 

scarce legal resources to older persons in the greatest social or economic need by 

developing a legal needs assessment; 2) create and maintain a high-quality statewide senior 

legal hotline at Legal Helplink; 3) create and maintain a high-quality statewide legal services 

delivery system integrated into the state broad aging service network; and 4) broaden the 

visibility and utilization of the new statewide legal services delivery system. Anticipated 

outcomes are that consumers and their caregivers will have greater access to legal 

assistance in addition to improved service and follow-up. Documentation of outcomes will 

focus on tracking project activities, customer outcomes and evaluations. 




Project Title: Model Approaches for Improving the District of Columbia’s Legal 

Services Delivery System 



Legal Counsel for the Elderly 

601 E Street, NW 



Year Amount 


Contact: 

Aaron Knight 

Tel. (202) 434-2107 

Email: aknight@aarp.org 



Total $100,000 

AARP Legal Counsel for the Elderly (LCE) through the District of Columbia (DC) Model 

Approaches Project intends to increase access to legal assistance for older persons, 

particularly those in greatest social or economic need. The project goal is to Improve access 

to and quality of legal services delivered to older DC residents by the hotline and related 

components of the legal delivery system, with a special emphasis on serving hard-to-reach, 

underserved, and limited-English speaking populations. The Objectives are: 1) engage 

stakeholders in evaluating the current system; 2) gather information on the legal needs 

particularly those with the greatest social or economic need; 3) improve the low-cost services 

of hotline, self-help offices, brief services, and pro bono project; 4) strengthen outreach 

approaches to better target those with the greatest need, focusing on their most critical legal 

needs; and 5) broaden support from key partners for the services LCE provides. Anticipated 

outcomes include measurable increases in: 1) access to legal services; 2) client satisfaction; 

and 3) client case outcomes. 




Project Title: Georgia Model Approaches Project 



Atlanta Legal Aid Society, Inc. 

Georgia Senior Legal Hotline 

151 Spring Street NW 


Contact: 

Amanda Styles 

Tel. (404) 614-3905 

Email: abstyles@atlantalegalaid.org 



Year Amount 


Total $100,000 


The Georgia Model Approaches project partners the Atlanta Legal Aid Society with the 

Department of Human Services Division of Aging Services, to strengthen Georgia’s legal 

services delivery system. The project goal is to increase the availability of high-quality, highimpact, 

low-cost legal services for Georgia’s most vulnerable seniors by improving and 

sustaining coordination among legal services providers, integrating legal services providers 

with the broader aging network, and investing in technology and strategic partnerships. The 

objectives are to: 1) assess the most critical legal needs of the most vulnerable seniors and 

the capacity of the legal services delivery system to meet those needs; 2) convene working 

groups of legal and social service providers to create integrated referral, outreach, and 

training systems that better meet the needs of vulnerable seniors and establish a permanent 

advisory body to ensure continued integration and visibility and statewide support; and 3). 

enhance the low-cost components of the legal services delivery system, the Hotline and 

volunteer attorneys, through technology and new programs. Anticipated outcomes are: 1) an 

integrated legal services delivery system that maximizes resources so that seniors have 

greater access to legal services, and allocates cases so that seniors are served by the most 

appropriate provider; 2) increased awareness by vulnerable seniors and social service 

providers of the legal rights of seniors and of the services available to protect those rights; 

and 3) more efficient and effective low-cost components of the legal services delivery system. 




Project Title: Model Approaches to Statewide Legal Assistance Systems 



Louisiana Governor’s Office of Elderly Affairs 

412 North 4th Street, 3rd Floor 


Contact: 

Jane A. Thomas 

Tel. (225) 342-7100 

Email: janeathomas@msn.com 


Fiscal 

Year 

Funding 

Amounts 









Total $199,308 


The goal of Louisiana's Model Approaches project is to increase access to legal services for 

seniors with the greatest social and economic need, utilizing the helpline and other legal 

services. The Legal Assistance Developer (Governor's Office of Elderly Affairs) is 

collaborating with the Louisiana Civil Justice Center (the helpline) and the legal service 

providers in Louisiana to develop a coordinated system of legal services to the 60 and older 

population. Project objectives include: 1) conducting a statewide legal needs assessment of 

seniors; 2) providing a statewide toll-free helpline to seniors; 3) developing packets and 

downloadable forms such as healthcare powers of attorney and living wills; 4) referring 

seniors who need direct representation to legal service providers; 5) completing a statewide 

reporting form for III-B providers to report quarterly; and 6) completing development of 

standards for targeting Louisiana's most vulnerable seniors. The expected outcomes are: 1) 

a statewide fully integrated and coordinated legal delivery system targeted to those seniors in 

greatest need; 2) increased access to legal services; 3) a statewide senior legal helpline; 4) a 

finalized reporting form for III-B providers; and 5) a meaningful reporting form for helpline 

data. The products expected are a completed needs assessment, a Title III-B reporting form, 

establishment of standards, senior-friendly packets, and Aging Disability and Resource 

Centers linkages to websites and toll free phone numbers. 


Program: Model Approaches to Statewide Legal Assistance 


Project Title: Model Approaches to Statewide Legal Assistance System 



Legal Services for the Elderly, Inc. 

5 Wabon Street 

August, ME 04330 

Contact: 

Jaye Martin 

Tel. (207) 620-3103 

Email: jmartin@mainelse.org 


Fiscal 

Year 

Funding 

Amounts 









Total $204,116 


The goal of Maine’s Model Approaches project is to increase the number of elders in Maine 

who seek and obtain ready access to high-quality legal assistance when their basic human 

needs are at stake, through the implementation of sustainable, low-cost delivery methods. 

Collaborative partners include Maine’s Office of Elder Services, Legal Services for the 

Elderly, Inc., five Area Agencies on Aging, the Long Term Care Ombudsman, Attorney 

General, private bar, and the University of Maine’s Law School, Dept. of Social Work, and 

Center on Aging. The objectives are: 1) to establish a collaborative leadership structure for 

elder legal service in Maine; 2) increase the capacity of the system through use of 

collaborative pro bono mechanisms; and 3) increase access to legal services by underserved 

groups of elders. The expected outcomes are: 1) participation by key agencies in a new 

leadership structure; 2) enhanced coordination of services; 3) adoption of a cooperative 

statewide outreach plan targeting hard-to-reach groups; and 4) an increase in the number of 

socially or economically disadvantaged elders receiving services, particularly minorities and 

non-English speakers. The products include a needs assessment with a focus on hard-toreach 

groups, a replicable interdisciplinary elder rights leadership structure, and collaborative 

low-cost approaches for expanding the capacity of a statewide legal services delivery system. 




Project Title: Massachusetts Senior Legal Assistance Project 



Legal Advocacy and Resource Center, Inc. 

197 Friend Street 9th Floor 

Boston, MA 02114-1802 


Year Amount 


Contact: 

Rosa A. Previdi 

Tel. (617) 603-1716 

Email: rprevidi@gbls.org 



Total $100,000 

The Legal Advocacy and Resource Center through the Massachusetts Model Approaches 

project will partner with the Massachusetts Executive Office of Elder Affairs to create a 

statewide legal service delivery system, with a focus on reaching those of greatest economic 

or social need, increasing the quality and quantity of elder legal services in Massachusetts 

by: ensuring referral to the most appropriate service; providing full representation; identifying 

all legal resources for older Massachusetts residents; streamlining the intake process; 

transferring intake information to partnering agencies; using paralegals and law students to 

resolve simpler challenges; and developing and using pro bono resources. Specific 

objectives are: 1) maximizing efficiency of existing legal services network by assessing 

current needs and strengths and convening an advisory committee of legal and aging service 

providers; and 2) developing and promoting a legal helpline to serve as first point of contact 

to provide elders with information, advice and referrals. Anticipated outcomes are: 1) 

establishment of a statewide legal helpline serving 2,000 additional seniors served per year 

by the legal service network in Years 2 and 3 of the grant; 2) enhanced active involvement of 

law schools in the legal services network; 3) increased capacity to address consumer and 

advanced directive issues; 4) increased availability of pro-se materials; and 5) increased 

collaboration among legal services providers. 








920 Wildwood Drive 

P.O. Box 570 


Contact: 

Marta J. Fontaine 

Tel. (573) 526-3246 

Email: marta.fontaine@dhss.mo.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $195,828 


The Missouri Department of Health and Senior Services is coordinating and enhancing 

existing limited and fragmented senior legal services by instituting a statewide toll-free phone 

line in conjunction with an online helpline. The goal is an integrated system of senior legal 

services that any consumer, senior or caregiver -- urban or rural, English or non-English 

speaking -- can access for information on legal issues and referrals to Title III-B and Legal 

Services Corporation funded services, or private attorneys providing pro bono or low-cost 

services involving critical needs. The target population includes rural and minority seniors, 

foreign-language speaking immigrants (primarily Spanish, Bosnian and Vietnamese), inhome 

service recipient populations assessed by Adult Protective Services and/or served by 

Medicaid waiver programs, and nursing facility residents. Objectives include: 1) conduct of a 

needs assessment to guide establishment of a toll free number paired with an online helpline 

to link seniors and their caregivers to legal information and services specific to their local 

area; 2) an increase in the amount of pro bono and low-cost hours of private attorneys for 

senior legal services; and 3) increased access to computers at community agencies, 

including senior centers and meal sites. Expected outcomes include: 1) increased 

awareness of senior legal issues and services; and 2) the integration of existing and 

additional services, resulting in better informed decisions on legal issues for Missouri seniors. 

The final products are to be a statewide senior legal phone helpline and companion online 

helpline, standard reporting and measurement tools, and additional legal service hours 

provided by Missouri Bar Association members. 







Legal Aid of Nebraska 

1904 Farnam Street, Suite 500 

Omaha, NE 68102 

Contact: 

Margaret Schaefer 

Tel. (402) 348-1069 x225 

Email: mschaefer@legalaidofnebraska.com 


Fiscal 

Year 

Funding 

Amounts 









Total $200,000 


The project goal is to ensure that elders with greatest social or economic need have access 

to quality legal assistance through an integrated service delivery system. The “Nebraska 

Model” will benefit the aging and legal services field of knowledge by developing a model 

addressing the unique needs of a large, predominantly rural state, with the rapidly increasing 

number of elders confronting geographic isolation as a chief barrier to access to legal 

services. Objectives are: 1) to foster linkages between Area Agencies on Aging and Legal 

Aid, and among legal aid providers, and the broader aging services system; 2) establish a 

statewide system to serve the most vulnerable, underserved elders; 3) integrate low-cost 

service delivery mechanisms with Title III-B legal services and the broader aging services 

delivery system; 4) promote awareness of legal services available; and 5) develop a 

statewide accountability system. Expected outcomes include: 1) continued provision of legal 

services via ElderAccessLine (helpine) to 1200 clients; 2) satisfaction ratings of at least 85%; 

legal services for minority elder populations that are over 50% low-income, over 1/3 

geographically isolated, English as a Secondary Language or Limited English Proficient, 15% 

Native Americans, African Americans, Hispanic or other minorities; and 3) measurable 

increase in calls from elders to the ElderAccessLine, with a measurable decrease in cost per 

person. Products will include a legal services inventory, culturally competent toolkit, 

marketing plan, outcomes-based service standards, and sustainability plan. 




Project Title: Model Approaches to Statewide Legal Services 



Legal Aid of North Carolina 

224 South Dawson Street 

Raleigh, NC 27601 

Contact: 

Angeleigh Dorsey 

Tel. (828) 236-1080 ext. 3106 

Email: angied@legalaidnc.org 


Fiscal 

Year 

Funding 

Amounts 









Total $187,908 


Legal Aid of North Carolina (LANC), in partnership with the North Carolina Division of Aging 

and Adult Services (DAAS), and Campbell University School of Law (Campbell), is 

developing an integrated, coordinated statewide legal assistance delivery system for lowincome 

seniors, with particular emphasis upon isolated, underserved, rural and minority 

seniors. Objectives are: 1) evaluation of the current legal assistance delivery system; 2) 

increased access to low-cost, quality legal assistance to seniors in the greatest need through 

expansion of the pilot LANC Senior Helpline into a statewide helpline serving all 100 

counties; and 3) establishment by Campbell of a senior law clinic and statewide conference 

for stakeholders to develop pro se materials and pro bono services as determined by a senior 

legal needs survey. The outcome will be sustainable, integrated, and coordinated access to 

low-cost legal assistance. The expected products from this project include the first North 

Carolina legal needs assessment, a new senior law clinic in the state capital, a statewide 

senior legal helpline, and a final report for the Administration on Aging. 







Pro Seniors, Inc. 

7162 Reading Road, Suite 1150 

Cincinnati, OH 45327 

Contact: 

Rhonda Y. Moore 

Tel. (513) 458-5506 

Email: rmoore@proseniors.org 


Fiscal 

Year 

Funding 

Amounts 









Total $200,000 


Pro Seniors, Inc., which has housed the Ohio Senior Legal Hotline since 1990, is developing 

with the support of Ohio’s Attorney General, Department of Aging, Area Agencies on Aging 

(AAAs), and legal services programs, a more integrated and coordinated senior legal 

services delivery system in Ohio to better meet the legal needs of the State’s large, growing, 

and in many cases, disabled and vulnerable senor population. Project objectives include: 1) 

enhancing and promoting access to legal services for Ohio seniors by strengthening the 

capacity of the helpline; 2) conducting an analysis of the current senior legal service delivery 

system; 3) fostering increased collaboration and coordination between legal services 

providers, including Title III-B providers, the helpline, pro bono providers, and the broader 

aging service delivery network, including AAAs; and 4) increasing legal services to 

underserved populations. Outcomes include 1) increasing helpline clients by 10%; 2) 

increasing by 10% each, the number of low-income, minority and rural helpline clients; 3) 

increasing effective helpline referrals to legal aid programs by 20%; and 4) increasing by 5% 

each, the percentage of low-income, minority and rural Title III-B clients. Products will 

include a quarterly elder law newsletter, a statewide elder law task force, an Ohio elder law 

resource website and listserv, and a matrix for helpline referrals to Title III-B programs and 

data on stakeholder participation, including survey results. 




Project Title: Model Approaches to Statewide Assistance Systems 



Rhode Island Legal Services, Inc 

56 Pine Street, Suite 400 

Providence, RI 02903 

Contact: 

Robert M. Barge 

Tel. (401) 274-2652 

Email: rbarge@rils.org 


Fiscal 

Year 

Funding 

Amounts 









Total $200,000 


Rhode Island Legal Services, Inc. is implementing a three-year program to increase access 

to legal assistance for seniors in Rhode Island. The plan seeks to develop a fully integrated, 

coordinated, low-cost state legal assistance network, the Rhode Island Senior Legal 

Assistance Network (RISLAN). RISLAN incorporates legal services providers, and the 

services of Rhode Island's Title III-B legal services provider, with Rhode Island's Aging and 

Disability Resource Center (the POINT), to ensure that all socially and economically 

disadvantaged seniors obtain the legal help they need. Objectives include: 1) conducting a 

legal needs assessment of senior Rhode Islanders; 2) collaborating with all stakeholders to 

build a network of legal services providers and pro bono programs; and 3) increasing 

coordinated access and availability of legal assistance at senior centers. Outcomes include: 

1) greater numbers of seniors experiencing increased security from eviction, foreclosure, or 

financial exploitation; and 2) seniors' lives improved by elimination of legal problems. 

Expected products are a statewide senior legal assistance plan, consumer, tax, and financial 

exploitation pamphlets, an electronic desk manual listing "frequently asked questions" of a 

legal nature, and an evaluation report. 








1301 Gervais St., Suite 200 

Richland, SC 29201 

Email: Contact: 

Catherine S. Angus 

Tel. (803) 734-9983 

Email: cangus@aging.sc.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $200,000 


The Lieutenant Governor’s Office on Aging will partner with South Carolina Legal Services 

(SCLS) and ten Area Agencies on Aging (AAAs) and Aging and Disability Resource Centers 

(ADRCs), to increase, improve, and enhance seniors’ access to legal services throughout 

South Carolina. Project goals are to: 1) increase visibility and accessibility of legal services 

for seniors, as well as the number of seniors receiving legal services; 2) conduct a needs 

assessment to identify specific populations and services needed; 3) develop and implement 

educational initiatives for the target population (including rural and low-income seniors and 

immigrant populations); and 4) support and expand SCLS’s intake line to provide telephone 

assistance or appropriate referral for Title III-B assistance. Planned outcomes include: 1) 

improved access to expanded legal services; 2) improved quality of life and independence for 

seniors; 3) development of a sustainable system for access to those services with ongoing 

collaboration; 4) participation by stakeholders after the project’s end; and 5) a system of 

ongoing data collection and assessment. Products will include an updated Guide to Laws 

and Programs Affecting Seniors, a DVD for mass distribution on futures planning/estates and 

the probate process, a referral system to legal assistance with data collection, and final grant 

reporting on outcomes including lessons learned. 




Project Title: Texas Elder Exploitation Project 



Texas Legal Services Center, Inc. 

Legal Hotline for Texans 

815 Brazos, Suite 1100 


Contact: 

Paula Pierce 

Tel. (512) 639-5414 

Email: ppierce@tlsc.org 



Year Amount 


Total $100,000 


The Texas Elder Exploitation Project will expand and coordinate the Legal Hotline for Texans 

and the State’s senior legal hotline, with the Texas Department of Aging and Disability 

Services and the State Legal Assistance Developer to reach exploited elderly with legal 

services. Its objectives are: 1) to develop a task force to build a model legal service delivery 

system for victims of exploitation; 2) to compile information on the legal needs of exploited 

elders and current system capacity to guide; development of the project; 3) to develop, test, 

and maintain the Texas Elder Exploitation Project as an expansion of the Legal Hotline for 

Texans; 4) to develop tools to sustain the project beyond AoA funding; 5) to establish 

outreach to effectively target limited legal resources to those in greatest need; and 6) to 

utilize leadership of the State Legal Assistance Developer to build support among 

stakeholders to provide ongoing input to implement, grow, and sustain the project. 

Anticipated Outcomes are: 1) increased financial security for seniors whose exploitation 

issues are resolved; 2) more effective collaboration among identified stakeholders to increase 

services available to exploited seniors; and 3) improved capacity of the legal service delivery 

system to address problems encountered by exploited seniors. 


Program: Model Approaches to Senior Legal Services 


Project Title: Model Approaches to Senior Legal Services 



Utah Legal Services, Inc. 

205 North 400 West 


Contact: 

Tarita Kisa Clayton 

Tel. (801) 924-3390 

Email: tclayton@utahlegalservices.org 


Fiscal 

Year 

Funding 

Amounts 

FY2010 $ 








Total $200,000 


The goal of Utah's project is to develop a well coordinated and integrated system of efficient, 

accessible, and targeted legal services for Utah seniors. The objectives are to: 1) create a 

statewide senior legal helpline; 2) conduct a legal needs assessment; 3) convene a Utah 

Elder Law Coalition to develop a comprehensive and integrated statewide legal service 

delivery plan; 4) target services appropriately to those most in need; and 5) expand, enhance 

and coordinate self-help delivery mechanisms. Measurable project outcomes include: 1) 

increase by 20% the number of seniors receiving services for high priority cases; 2) increase 

by 30% the number of Utah's targeted senior population (low-income, homebound, rural, 

minority, and limited English-speaking) that will have access to legal services; and 3) 

increase by 15% the awareness of available legal services and ability to identify legal issues, 

by the broader community-based aging network. The proposed products include a legal 

needs assessment, comprehensive and integrated statewide delivery plan, written self-help 

materials, video files, podcast audio files, Spanish language presentation materials, a "How 

to Manual," summary journal articles, and project methodology and lessons learned 

presentations. 







Vermont Legal Aid, Inc. 

PO Box 1367 

264 North Winooski Avenue 

Burlington, VT 05402 

Contact: 

Michael Benvenuto 

Tel. (802) 863-5620 

Email: mbenvenuto@vtlegalaid.org 


Fiscal 

Year 

Funding 

Amounts 









Total $200,000 


Vermont Legal Aid, Inc. is evaluating, coordinating and expanding the delivery of legal 

services to seniors throughout the State of Vermont. The goal of the project is to improve the 

lives of Vermont seniors by providing greater access to comprehensive and coordinated legal 

services in all areas of the State. This is being accomplished by establishing a coordinated 

service delivery system for seniors statewide, including the piloting of a helpline for seniors 

focused on consumer laws problems. Target populations include rural seniors (comprising 

approximately 82% of the senior population), with particular emphasis upon homebound 

seniors, immigrant, and limited-English-speaking seniors. The expected outcome of this 

project is a coordinated system for the intake, referral, and delivery of legal services that 

increases access to services for seniors statewide. The expected products from this project 

include a legal needs study for the State of Vermont; a comprehensive and integrated intake 

and referral system for seniors; and a pilot project of a statewide helpline focused on 

consumer law issues for seniors, which can serve as a template for integrating helpline 

services into a full-service organization. 




Project Title: Creation Of a Coordinated, Efficient, Cost-Effective, Quality Legal 

Services Delivery System for Senior West Virginians 



West Virginia Senior Legal Aid, Inc. 

235 High Street, #519 

Morgantown, WV 26505-5454 


Year Amount 


Contact: 

Cathy McConnell 

Tel. (304) 296-0082 

Email: seniorlegalaid@yahoo.com 



Total $100,000 

The goal of the West Virginia Model Approaches project is to create a comprehensive, wellintegrated, 

cost-effective, efficient, and high quality legal services delivery system for needy 

senior West Virginians. Its objectives are to: 1) convene an Elderlaw Advisory Group to 

make our legal services delivery efficient, effective, higher quality, targeted, and broader 

access; 2) conduct a legal needs assessment and delivery system assessment; 3) costeffectively 

dispel legal mythology among seniors; 4) efficiently and cost-effectively provide 

quality, relevant legal trainings online; 5) improve states system of response to financial 

exploitation of seniors by people in positions of trust; 6) reach out to and serve the special 

legal needs of LGBT seniors; 7) bring West Virginia Senior Legal Assistance and Legal 

Assistance of West Virginia together to carefully integrate programs services to seniors; and 

8) enhance pro bono referral especially to target populations. Anticipated Outcomes are: 1) 

the law and aging community in state will learn the legal needs of the neediest seniors; 2) 

target populations of seniors will have increased awareness of how legal assistance can 

preserve independence, and increased access to quality legal services; 3) seniors and senior 

service providers will receive valuable elder law information geared toward helping seniors 

preserve their independence; and 4) increased number of hours pro bono attorneys devote to 

serving seniors in our state. 


National Legal Assistance Centers 

The 1984 Older Americans Act (OAA) Amendments (P.L. 98-459) required the Administration 

on Aging to make grants and enter into contracts to provide a national legal assistance 

support system of activities to State and area agencies on aging for providing, developing, or 

supporting legal assistance for older individuals. First funded in FY1985, National Legal 

Assistance Centers have provided expertise on laws affecting the elderly to State and local 

legal service providers funded under OAA Title III and legal service developers funded under 

OAA Title VII. Authority for support of the Centers is currently under Title IV Section 420 

which in calling for AoA to support a national legal assistance support system, specifies that it 

is to provide, develop and support it through case consultations; training; provision of 

substantive legal advice and assistance; and assistance in the design, implementation, and 

administration of legal assistance delivery systems to local providers of legal assistance for 

older individuals. 

In recent years AoA has supported the National Legal Assistance Centers through a 

competitive process of awarding three year grants as cooperative agreements. In FY2008 

changed its process to require applicants to compete for options reflecting the requirements 

of the Act asking for the national organizations to apply under one or more of the five (5) 

options in the FY2008 program announcement which were: case consultation, training on 

law and aging; technical assistance/legal and aging systems development; information and 

resource development and dissemination; and website content development. The five project 

awards made under this announcement included in this compendium received their third year 

continuation funding in FY2010. 

Information about the Centers can be found on the AoA website: 

http://www.aoa.gov/AoARoot/AoA Programs/Elder Rights/Legal/national legal.aspx 


Program: National Legal Assistance Centers 

Grant Number: 90LA0001 

Project Title: National Legal Resource Center – Information and Development 



American Bar Association Fund for Justice and Education 

740 15th Street, NW 


Contact: 

Holly Robinson 

Tel. (202) 662-8694 

Email: robinsoh@staff.abanet.org 

AoA Project Officer: Omar Valerde 

Fiscal 

Year 

Funding 

Amounts 









Total $520,000 


The American Bar Association (ABA) Fund for Justice and Education, through the ABA 

Commission on Law and Aging, will develop and disseminate a wide range of information and 

resources on law and aging as the primary activity under funding Option IV: Information and 

Resource Development and Dissemination. The ABA will make informational materials and 

other resources available to professionals and advocates in law and aging including: Title III 

B attorneys, Legal Service Corporation attorneys, Legal Assistance Developers, pro bono 

attorneys, elder law and consumer law attorneys in the public and private sectors, members 

of the judiciary, law enforcement, aging services staff of area agencies on aging and Aging 

and Disability Resource Centers (ADRCs), employees and volunteers of organizations 

providing legal and aging services to older persons (including low income minorities and 

Native Americans), older consumers, and other professionals and advocates within 

organizations serving older persons. The informational materials and other resources on law 

and aging to be developed and/or disseminated will include: research and findings on cutting 

edge issues of elder law; newsletters; fact sheets; issue briefs; self-help manuals; 

educational and outreach materials; results of demonstration projects impacting aging and 

legal systems; and models of innovation in legal and aging service delivery. In addition, a 

primary activity under Option IV will involve the administration of a professional listserve and 

the development of content for the NLRC website. Anticipated Outcomes are that the project 

will: 1) support the leadership, knowledge, and systems capacity of states, legal services 

providers, area agencies on aging, ADRCs, and other organizations serving older persons; 

and 2) enhance the quality, cost effectiveness, and accessibility of legal assistance and elder 

rights programs provided to older persons. 




Project Title: Building the Legal Capacity of the Aging Network through Case 

Consultations 



National Senior Citizens Law Center 

1444 Eye Street NW, Suite 1100 


Contact: 

Lynda Martin-McCormick 

Tel. (202) 289-6976 

Email: lmm@nsclc.org 


Fiscal 

Year 

Funding 

Amounts 









Total $612,000 


The National Senior Citizens Law Center (NSCLC) provides case consultation as the primary 

activity under funding Option I for case consultation. NSCLC makes case consultation 

available to professionals and advocates in law and aging, including Title III-B legal 

assistance providers, Legal Services Corporation (LSC) providers, Legal Assistance 

Developers, elder law and consumer law attorneys in the public and private sectors, 

members of the judiciary, aging services staff of area agencies on aging and Aging and 

Disability Resource Centers (ADRCs), and other professionals and advocates within 

organizations serving older persons. NSCLC will provide intensive and tailored advice in the 

following legal subject matter areas (in partnership with the National Consumer Law Center): 

Healthcare benefits; Long term care in institutional or home and community based settings; 

Older Americans Act services; Social Security (including SSI and SSDI); Medicare (including 

Medicare Part D); Medicaid (including the financing of home and community based care); 

Housing (including defense against foreclosures or evictions); Pension benefits; Abuse, 

neglect, and financial exploitation of vulnerable elders; Consumer fraud/scams; Guardianship 

(including the defense of guardianship); Insurance benefits; Debt collection harassment; 

Mortgage fraud and predatory lending; and Credit repair and counseling. Anticipated 

outcome are that the project will: 1) support the leadership, knowledge, and systems 

capacity of states, legal services providers, Area Agencies on Aging, ADRCs, and other 

organizations serving older persons; and 2) enhance the quality, cost effectiveness, and 

accessibility of legal assistance and elder rights programs provided to older persons. 


Program: Program: National Legal Assistance Centers 


Project Title: National Elder Rights Training Project 



National Consumer Law Center 

77 Summer Street, 10th Floor 

Boston, MA 02110-1006 

Contact: 

Odette Williamson 

Tel. (617) 541-8010 

Email: owilliamson@nclc.org 

AoA Project Officer: Omar Valerde 

Fiscal 

Year 

Funding 

Amounts 









Total $462,000 


National Consumer Law Center is training aging and legal service providers and advocacy 

networks as the primary activity under the funding option Training on Law and Aging. 

Training and education is available to advocates and professionals in law and aging, 

including Legal Assistance Developers, Title III-B attorneys, Legal Service Corporation 

attorneys, pro bono attorneys, elder law and consumer law attorneys, judiciary members, law 

enforcement, Area Agencies on Aging and Aging and Disability Resource Centers (ADRCs), 

employees and volunteers of organizations providing legal or aging services to older persons 

(inc. low income minorities and Native Americans), older consumers, and other professionals 

and advocates serving older persons. Partnering with the National Senior Citizen's Law 

Center, training topics offered include: 1) application of laws on Long Term-Care in 

institutional and community-based settings; financing health care through Medicare/Medicaid; 

financing health care through appropriate private pay options; guardian/conservator and 

surrogate decision-making; housing and public benefits; Older Americans Act services; 

predatory mortgage lending; home foreclosure; and vulnerable older adult abuse, neglect, 

self- neglect, and exploitation; 2) application of laws on fraud, targeting older consumers, 

including identity theft, investment fraud, and other financial crimes; 3) proper identification 

and /referral of legal and elder abuse issues by aging and legal service providers; 4) 

coordination/integration of legal and aging service delivery systems, inc. enhanced linkage of 

legal services with ADRCs; 5) target and enhance access to legal services for older persons 

in most social and economic need; 6) development of measurable outcomes for legal service 

delivery systems that quantify beneficial impact of legal services on older persons; and 7) 

collaborations to enhance access to quality legal and aging services for older persons most in 

need. The anticipated outcome is enriched quality. improved cost effectiveness and 

accessibility of legal assistance and elder rights programs for older persons. 




Project Title: National Legal Resource Center: Technical Assistance for Legal 

and Aging Systems Development 



The Center for Social Gerontology 

2307 Shelby Ave 

Ann Arbor, MI 48103-3803 

Contact: 

Penelope A. Hommel 

Tel. (734) 665-1126 

Email: phommel@tcsg.org 


Fiscal 

Year 

Funding 

Amounts 









Total $545,021 


The Center for Social Gerontology (TCSG) provides technical assistance in the design, 

implementation, administration, and evaluation of legal assistance delivery and elder rights 

advocacy systems. The grantee works with states, Area Agencies on Aging (AAAs), Aging 

and disability Resource Centers (ADRCs), and legal services providers to improve the 

delivery of legal assistance and elder rights programs, with an emphasis on the 

implementation of well-integrated and cost effective legal service delivery systems. TCSG 

provides technical assistance in the following areas: 1) technical assistance to states, AAAs, 

ADRCs, and legal providers involved in the Model Approaches demonstration projects; 2) 

technical assistance to state and local organizations in the development of intake and 

assessment tools; 3) technical assistance to state and local organizations in the development 

of needs assessment tools; 4) technical assistance to state and local organizations in the 

development of systems capacity assessment tools; 5) technical assistance to state and local 

organizations in the development of outreach strategies; 6) technical assistance to state and 

local organizations in the development of outcomes measures and reporting/data collection 

systems; 7) technical assistance to state and local organizations in the development of legal 

service delivery strategic plans; 8) technical assistance to state and local organizations in the 

development of legal service delivery standards; 9) technical assistance to AAAs, ADRCs, 

and local legal service providers, in the integration of legal assistance programs into 

community based service delivery systems; 10) technical assistance to state and local 

agencies and organizations on guardianship issues; and 11) technical assistance to state 

and local organizations on innovative funding sources for legal assistance and elder rights 

programs. 




Project Title: Center for Elder Rights Advocacy (C.E.R.A.) 



Elder Law of Michigan, Inc 

3815 W. St. Joseph St., Suite C-200 

Lansing MI 48917 

Contact: 

Keith Morris 

Tel. (866) 949-2372 

Email: kmorris@ceraresource.org 


Fiscal 

Year 

Funding 

Amounts 









Total $395,956 


The Center for Elder Rights Advocates (CERA) provides direct technical assistance to state 

and local organizations in the design, implementation, administration, and evaluation of 

senior legal helplines as the primary activity under funding Option III Technical 

Assistance/Legal and Aging Systems Development. CERA is working with states, area 

agencies on aging, Aging and Disability Resource Centers (ADRCs), and legal services 

providers to expand and improve well integrated and cost effective legal service delivery 

systems that involve legal helplines and interface seamlessly with the aging services network. 

The project will support the leadership, knowledge, and systems capacity of states, legal 

services providers, area agencies on aging, ADRCs, and other organizations serving older 

persons and enhance the quality, cost effectiveness, and accessibility of legal assistance and 

elder rights programs provided to older persons. 


Senior Medicare Patrol (SMP) 

The Senior Medicare Patrol (SMP) program empowers seniors through increased awareness 

and understanding of healthcare programs and helps seniors to protect themselves from the 

economic and health-related consequences of Medicare and Medicaid fraud, error and 

abuse. SMP projects work to resolve beneficiary complaints of potential fraud in partnership 

with state and national fraud control/consumer protection entities, including Medicare 

contractors, state Medicaid fraud control units, state attorneys general, the Department of 

Health and Human Services Office of the Inspector General and the Center for Medicare and 

Medicaid Services. 

The SMP program was established in 1997 with enactment of P.L. 104-209, the Omnibus 

Consolidated Appropriations Act of 1997 which included language directing the AoA to 

establish demonstration projects that utilize the skills and expertise of retired professionals in 

identifying and reporting error, fraud and abuse. Senator Harkin who introduced this 

language was impressed by the results of a previous Administration on Aging (AoA) 

demonstration, Operation Restore Trust, which addressed fraud and abuse of Medicare and 

Medicaid in nursing homes and among durable equipment providers. SMP operations 

through projects in all states, the District of Columbia, Puerto Rico, Guam and the U.S. Virgin 

Islands and recruits and trains nearly 4,500 volunteers to reach beneficiaries. 

AoA held competitions for new capacity building grants in FY2010 and made continuation 

awards to grants awarded in FY2009 and FY2008 to expand the reach of programs 

statewide. Additional information about SMP may be found on the AoA website: 

http://www.aoa.gov/AoARoot/AoA Programs/Elder Rights/SMP/index.aspx 


Senior Medicare Patrol (SMP) Program – Capacity Building Grants 

The Administration on Aging (AoA) announced a funding opportunity in FY2010 for Senior 

Medicare Patrol (SMP) programs to compete in one of several categories to increase their 

capacity to educate beneficiaries on health care fraud in Medicare and Medicaid programs. 

These categories included specified States with high fraud rates, States at greatest risk for 

health care fraud and abuse, and/or States where HHS/DOJ Health Care Fraud Prevention 

and Enforcement Force Action Team (HEAT) Strike Force Teams have been established. 

Increased funding for all current (incumbent) SMP grantees was believed necessary to reach 

more Medicare and Medicaid beneficiaries, their families and caregivers; to expand and 

enhance their volunteer work force and risk management; to expand outreach and education 

to beneficiaries statewide; and to manage beneficiary inquiries and complaints in a timely, 

professional manner. 


Program: Senior Medicare Patrol (SMP) Program – Capacity Building Grants 

Grant Number: 90MP0077 

Project Title: Alabama Senior Medicare Patrol- Capacity Building Grant 




770 Washington Ave., Suite 570 

Montgomery, AL 36130 

Contact: 

Robyn James 

Tel. (334) 353-9273 

Email: Robyn.James@ADSS.Alabama.gov 

AoA Project Officer: Dorothy E. Smith 

Fiscal 

Year 

Funding 

Amounts 









Total $150,000 


The Alabama Department of Senior Services (ADSS) supports this one-year SMP (Senior 

Medicare Patrol) program in collaboration with the 13 Area Agencies on Aging. The goal of 

the program is to increase education to beneficiaries, caregivers, providers, and the public to 

protect, detect, and report healthcare waste, fraud, and abuse. The objective is to expand 

SMP services and increase the number of SMP volunteers to build program capacity for the 

long term. The expected outcomes include: 1) a new and improved statewide SMP 

volunteer program; 2) an increase in SMP program activities, 3) an expansion of education 

and services to the highly rural, low-income, and hard-to-reach communities; 4) an additional 

state level staff person to assist the SMP Director; and 5) an increase in the number of SMP 

volunteers. The program products include a new volunteer program training curriculum and 

new volunteer recruitment materials. 




Project Title: Alaska Senior Medicare Patrol Capacity Building Grant 




Senior and Disabilities Services 

550 West 8th Avenue 

Anchorage, AK 99501-3518 

Contact: 

Judith Bendersky 

Tel. (907) 269-3669 

Email: judith.bendersky@alaska.gov 

AoA Project Officer: Terry W. Duffin 

Fiscal 

Year 

Funding 

Amounts 









Total $50,000 


The Alaska Senior Medicare Patrol (SMP) Program educates and empowers Alaskan seniors 

through its network of agency relationships and volunteer counselors. The SMP Expansion 

Grant will enable the Alaska SMP to enhance its capacity by developing online training 

modules and online certification and coordinate volunteer training, counseling and outreach 

activities throughout Alaska. The SMP project is continually strengthening its collaborative 

partnership with individuals and agencies throughout the state including current SMP/Sate 

Health Insurance Information Program (SHIP volunteers, the Division of Insurance, the Office 

of Elder Fraud and Abuse and the Better Business Bureau. 


Program: Senior Medicare Patrol Capacity Building Grants 


Project Title: Arizona Senior Medicare Patrol Project 




Division of Aging and Adult Service 

1789 West Jefferson, 950A 

Phoenix, AZ 85007-3202 

Contact: 


Tel. No. (602) 542-5757 


AoA Project Officer: Christine Ramirez 

Fiscal 

Year 

Funding 

Amounts 









Total $300,000 


The Arizona Senior Medicare Patrol (ASMP) Project located within the Department of 

Economic Security's (DES) Division of Aging and Adult Services (DAAS) is a one-year project 

to develop innovative health care fraud prevention activities. The goal is to build and 

strengthen the volunteer base. The objective is to interface with the Centers for 

Medicare/Medicaid Services (CMS), CMS contractors, law enforcement and other state 

partners to develop or implement new public awareness strategies about the incidence and 

prevalence of Medicare fraud. The expected outcomes are: 1) an increased awareness of 

beneficiaries, including those who are isolated and hard-to-reach, of how to detect and 

prevent Medicare/Medicaid error, fraud, and abuse; 2) an increased number of volunteers 

within Area Agencies on Aging (AAA) with knowledge to educate and investigate on behalf of 

beneficiaries, their families and caregivers on Medicare/Medicaid error, fraud, and abuse; and 

3) an increased understanding of tools to improve ASMP. The products will include training 

modules and printed material on information and education in the prevention and knowledge 

of identifying health care errors, fraud, and abuse. 




Project Title: Senior Medicare Patrol Project 



Arkansas Department of Human Services 


700 Main Street 

PO Box 1437, Slot S-530 


Contact: 

John Pollet 

Tel. (501) 682-8504 

Email: john.pollett@arkansas.gov 

AoA Project Officer: Lisa J.Theirl 

Fiscal 

Year 

Funding 

Amounts 









Total $100,000 


The Arkansas Senior Medicare Patrol (SMP) grant is a one-year grant to expand the capacity 

of the state SMP project to recruit, train, manage, and support an increased number of 

volunteers to handle the increased number of inquiries generated by expansion efforts. The 

goals are: 1) to expand and enhance the SMP volunteer workforce; 2) to expand SMP 

outreach and beneficiary education statewide through media spots and innovative methods; 

and 3) to integrate all healthcare fraud fighting activities within the Arkansas DHS through 

collaboration with the state Medicaid Office. The objectives are: 1) to expand program 

coverage into additional communities, with emphasis on the Delta counties recently added to 

the service area of Tri-County Rural Health Network (our sub-grantee partner on the 2008 

2010 Senior Medicare Patrol Integration (SMPI) grant); 2) to enhance our ability to manage 

beneficiary inquiries and complaints through recruitment and training of local RSVP and 

AARP volunteers to work in the office; and 3) to develop a strong network of partners/subgrantees 

building solid volunteer bases. The expected outcomes are: 1) an increased 

number of calls to the hotline and greater awareness of the program in event attendees and 

hotline callers (to be determined via a survey instrument); 2) an enhanced ability to prevent 

Medicare/Medicaid fraud and prosecute fraudulent providers. The products expected from 

this project include a survey to measure attendees and hotline callers and data on the level of 

healthcare fraud perpetrated in Arkansas. 




Project Title: Senior Medicare Patrol Expansion and Capacity Building Grant 

Project Period: 09/30/2010 – 09/30-2011 


California Health Advocates (CHA) 

5380 Elvas Avenue Suite 124 


Contact: 

Julie Schoen 

Tel. No. (714) 560-0309 

Email: jschoen@cahealthadvocates.org 

AoA Project Officer: Sau Wo D. Lam 

Fiscal 

Year 

Funding 

Amounts 









Total $430,000 


California Health Advocates (CHA), the current grant holder of the California Senior Medicare 

Patrol project, collaborates closely with the Center for Medicare and Medicaid Services 

Integrity Field Office in Los Angeles. The goal of this project is to fully utilize community 

resources to educate the public to protect, detect and report fraud and abuse of the Medicare 

program. The approach will be to expand services by doubling the number of SMP 

volunteers and formalized coordination with local State Health Insurance Information 

Program (SHIPs). The objectives are: 1) to establish a statewide SMP 800 number; 2) to 

recruit and train at least one SMP volunteer liaison for each of the 24 SHIPs in California; 3) 

to provide continuous training and in-services to volunteers and the public via webinars; and 

4) to establish a fully operational Northern California SMP branch office to expand outreach. 

The expected outcomes are: 1) double the current number of active SMP volunteers 

statewide and manage their activities effectively; 2) increase accountability and data 

collection of the number and types of telephone inquiries received through a call data base; 

and 3) expand the number and types of education events given throughout the state as well 

as media outreach, specifically targeting underserved/non-English speaking communities. 

The products from this project: a larger coordinated, educated and accountable volunteer 

base; an 800 line that is solely dedicated to SMP; and webinars and products that will be 

shared with all of our partners. 




Project Title: Colorado Senior Medicare Patrol (SMP) Capacity Building 



Colorado Department of Regulatory Agencies 

Division of Insurance 

1560 Broadway, Suite 850 


Contact: 

Suzanne R. Sigona 

Tel. (303) 894-7541 

Email: suzanne.sigona@dora.state.co.us 

AoA Project Officer: Courtney L. Hoskins 

Fiscal 

Year 

Funding 

Amounts 









Total $100,000 


Colorado Senior Medicare Patrol (SMP) operated through the Colorado Division of Insurance, 

supports this SMP Capacity Building project. The goal of the SMP program is to support 

activities of volunteer recruitment and community outreach to enhance-improve-expand 

Medicare beneficiaries' ability to detect and report circumstances of potential fraud and 

abuse. The objectives are: 1) to recruit more volunteers; 2) to train volunteers; 3) to develop 

infrastructure to support a coordinated and collaborative approach to the management and 

support of volunteers; and 4) to institute a comprehensive program that educates a wider 

range of citizens of Colorado who are exposed to incidents of Medicare fraud and abuse. 

The expected outcomes of this project are: 1) a higher level of support and engagement of 

our currently contracted SMP programs (statewide); 2) increased knowledge of beneficiaries 

to activities that constitute fraud and abuse; 3) increased reporting of fraudulent or abusive 

activities, 4) increase in Medicare funds recovered from abusive or fraudulent activities; and 

5) increased savings to beneficiaries. Products will include: an 800 toll free line; statistical 

reports; ads; and training materials. 




Project Title: Connecticut Senior Medicare Program (SMP) Expansion Project 







Contact: 

Dee White 

Tel. (860) 425-5008 

Email: dee.white@ct.gov 

AoA Project Officer: Gene Brown 

Fiscal 

Year 

Funding 

Amounts 









Total $100,000 


The Connecticut Department of Social Services, State Unit on Aging, supports this one year 

Health Care Fraud Prevention Program Expansion and Senior Medicare Patrol (SMP) 

Capacity Building Grant in collaboration with Connecticut's Regional Area Agencies on Aging. 

The goal of this project is to enhance the Senior Medicare Patrol (SMP) program capacity by 

increasing and supporting the SMP volunteer workforce and expanding SMP outreach, fraud 

awareness and education to Medicare beneficiaries throughout the state. The objectives are: 

1) to improve SMP project efficiency through increased number of SMP volunteers; 2) to 

enhance the SMP volunteer training strategy; 3) to expand SMP outreach and education to 

beneficiaries, caregivers, targeting hard-to-reach and isolated populations; 4) to expand SMP 

project's ability to manage beneficiaries' fraud inquiries and complaints in a timely and 

professional manner. The expected outcomes include the following: 1) increased number of 

volunteers enrolled in the SMP project; 2) expanded SMP program volunteer training 

initiatives; 3) increased awareness of Medicare fraud, waste and abuse issues by 

beneficiaries and caregivers: and 4) increased reporting of suspected fraud, waste, or abuse 

resulting in savings or cost avoidance attributable to the project. Products will include 

Medicare Fraud Tip Sheets, webinar training courses, Medicare Fraud Awareness 

Bookmarks, Scam Alert Boards, Caregivers' Fraud Educational CDs for Caregivers. 




Project Title: Delaware Senior Medicare Patrol (SMP) Capacity Building 




1901 N. DuPont highway, Main Building Annex 


Contact: 

Cynthia Allen 

Tel. (302) 255-9390 

Email: cynthia.allen@state.de.us 

AoA Project Officer: Carmen D. Sanchez 


Fiscal 

Year 

Funding 

Amounts 









Total $50,000 

The Division of Services for Aging and Adults with Disabilities (DSAAPD) supports this one 

year Senior Medicare Patrol (SMP) Capacity Building Project in collaboration with the State of 

Delaware Aging and Disability Resource Center (ADRC), Delaware Aging Network (MOT 

Senior Center), and Lenape Indian Tribe of Delaware. The goal is to expand the capacity of 

the existing SMP project by developing new innovations in a more comprehensive manner 

throughout the state. The objectives are: 1) to recruit, screen, train, manage and support an 

increased number of SMP volunteers and 2) to utilize these volunteers to effectively expand 

SMP outreach to beneficiaries in local communities with a result of enhanced SMP capacity 

for performance management. The expected outcomes are: 1) increased outreach, 

education and training efforts to the underserved and 2) increased SMP activities that are 

accurately tracked, recorded and reported. Products include Volunteer Services 

Coordinator/Case Manager (VSC/CM) position toolkit, Case Manager rolling file, SMP Site 

toolkit with strategic plan for outreach activities and technological marketing through an 

internet provider. 




Project Title: Senior Medicare Patrol of the District of Columbia 




601 E Street, NW, Building A, A4 


Contact: 

Jan May 

Tel. (202) 434-2164 

Email: jmay@aarp.org 

AoA Project Officer: Barry F. Klisberg 

Fiscal 

Year 

Funding 

Amounts 









Total $50,000 


This is a one-year grant to expand the capacity of the state Senior Medicare Patrol (SMP) 

project to recruit, train, manage, and support an increased number of SM P volunteers to 

handle the increased number of inquiries generated by expansion efforts. The goal of the 

Senior Medicare Patrol of the District of Columbia SMP, a project of Legal Counsel for the 

Elderly (LCE), is to educate DC Medicare and Medicaid beneficiaries and caregivers on how 

to detect and report health care fraud, error, and abuse. The objectives are: 1) to empower 

seniors their families and caregivers through increased awareness and understanding of 

health care programs and to protect them from the economic and health-related 

consequences associated with Medicare and Medicaid fraud, error, and abuse; 2) to expand 

and enhance our volunteer workforce; 3) to expand SMP outreach and education; 4) to 

expand our ability to manage beneficiary inquiries and complaints in a timely professional 

manner; and 5) to improve and enhance SMP program and volunteer management. The 

expected outcomes are: 1) increased number of volunteers, including bi-lingual volunteers; 

2) increased visibility through radio, television, print and online media; and 3) increased 

number of complaints and inquiries handled in a timely manner. Products will include 

volunteer training materials; ads and reports for the media. 




Project Title: Florida Senior Medicare Patrol Program Expansion and 

Capacity Building 



Area Agency on Aging of Pasco-Pinelles, Inc. 

9887 4 th Street, Suite 100 

St. Petersburg, FL 33702 

Contact: 

Sally Gronda 

Tel. No. (727) 570-9696 

Email: grondas@elderaffairs.org 

AoA Project Officer: Ronald S. Taylor 

Fiscal 

Year 

Funding 

Amounts 









Total $430,000 


This is a one-year grant to develop strategies for more direct and effective Senior Medicare 

Patrol (SMP collaboration with the Department of Justice (DOJ) Health Care Fraud 

Prevention and Enforcement Action Team (HEAT) Strike Force units in high Center for 

Medicare and Medicaid Services (CMS) identified fraud areas. The goal of this SMP 

expansion program is to expand the capacity of the state SMP project to recruit, train, 

manage, and support an increased number of SMP volunteers to handle the increased 

number of inquiries generated by expansion efforts. The objectives are: 1) to outreach to 

media, 2) to increase staff capacity to handle program expansion; and 3) to educate 

beneficiaries/consumer on the three tenets of the SMP Program - protect, detect, and report. 

Expected outcomes include: 1) a significant increase in the number of volunteers and their 

participation in program activities; 2) a timely exchange of ideas and information between 

SMP and the Tampa/Miami HEAT Strike Force; 3) an increase in media outreach throughout 

the state; and 4) assignment of staff/consultants to geographic regions, in order to maximize 

our outreach efforts. Products from this program will include semi-annual reports to AoA and 

OIG, a new updated web site and marketing and educational materials (English, Spanish, 

and Creole). 




Project Title: Senior Medicare Patrol Expansion and Capacity Building 





2 Peachtree St. 


Contact: 

Belinda J. Jones 

Tel. No. (404) 657-8756 

Email: bjjones@dhr.state.ga.us 


Fiscal 

Year 

Funding 

Amounts 









Total $300,000 


GeorgiaCares consists of the State Health Insurance Assistance Program (SHIP) and the 

Senior Medicare Patrol (SMP). The goals of this one-year grant proposal are to improve the 

management and coordination of statewide volunteer efforts and to increase capacity of 

outreach through the expansion and development of new partnerships. The objectives are: 

1) to hire a volunteer coordinator; 2) to implement coordinated volunteer administration 

including risk management; 3) to ensure that all GeorgiaCares hotline counselors are 

adequately trained on SMP; 4) to develop new partnerships with state and local agencies; 5) 

to increase the number of at-risk beneficiaries receiving education on how to detect and 

prevent health care fraud; and 6) to increase media spots to expand outreach to 

Medicare/Medicaid beneficiaries, their families and caregivers. The expected outcomes of 

this grant are: 1) increased identification of health care fraud hot spots within Georgia; 

greater visibility of media; and 2) expanded number of trained SMP volunteers including duallanguage 

volunteers. The products from this grant proposal include a public awareness 

campaign that includes volunteer/beneficiary highlights, use of social networking sites, SMP 

labels with the hotline number for placement on beneficiaries Durable Medical Equipment 

(DME) and financial exploitation/scam alerts, risk management materials added to SMP 

volunteer recruitment packets, and completion of a semi-annual and final report including 

lessons learned and the project evaluation. 




Project Title: Senior Medicare Patrol Capacity Building Grant 



Guam Department of Public Health and Social Services 

Division of Senior Citizens 

123 Chalan Kareta 

Mangilao, GU 96913- 6304 

Contact: 

J. Peter Roberto 

Tel. (671) 736-7102 

Email: caring.communities@yahoo.com 

AoA Project Officer: Anna H. Cwirko-Godycki 

Fiscal 

Year 

Funding 

Amounts 









Total $20,000 


The Guam Senior Medicare Patrol (SMP) remains committed to recruit retired professionals 

to serve as volunteers to educate Medicare beneficiaries on how to prevent, detect, and 

report health care error, fraud and abuse. The goal is to enhance current efforts to increase 

and support the volunteer workforce thus expanding outreach and education efforts 

throughout the island. The objectives are: 1) to develop a systematic plan of implementation 

to expand its organizational capacity; 2) to expand regular outreach to disseminate project 

information through the expanded volunteer workforce to expand program coverage; 3) to 

establish new partnerships to strengthen outreach to beneficiaries considered at greatest risk 

from fraud; and 4) to evaluate expanded project activities to improve the efficiency of the 

Guam SMP project. The expected outcomes are: 1) an increased number of volunteers 

trained; 2) an increased number of group education sessions; and 3) an increased number of 

outreach activities. Products will include an enhanced volunteer training manual. 




Project Title: Senior Medicare Patrol Project (SMP Hawaii) 



Hawaii Department of Health 




Contact: 


Tel. (808) 586-0100 



Fiscal 

Year 

Funding 

Amounts 









Total $88.750 


The goal of this project is to expand the capacity of Senior Medicare Patrol (SMP) Hawaii to 

conduct outreach and education about Medicare and Medicaid fraud, abuse, and errors to 

beneficiaries and their caregivers, families, and communities throughout the state of Hawaii. 

The objectives are: 1) to recruit increased numbers of SMP volunteers in all four Hawaii 

counties; 2) to recruit dual-language SMP volunteers to reach targeted limited English 

proficient (LEP) populations; 3) to provide SMP volunteers with training to expand their 

capacity to conduct outreach, answer beneficiary inquiries, and resolve complex issues; 4) to 

expand outreach statewide by increasing the numbers of group presentations; developing 

radio public service announcements (PSAs) about health care fraud, abuse, and errors; and 

creating a stand-alone SMP Hawaii website to increase access to education and to facilitate 

reporting of health care fraud, abuse, and errors; and 5) to improve project management by 

simplifying volunteer reporting requirements. Expected outcomes are: 1) increased number 

of people who will be able to detect fraud and errors and report cases to SMP Hawaii; 2) 

improve beneficiary wellbeing by answering their inquiries and resolving complaints. 

Products include a website, training videos, a volunteer-recruitment public service 

announcement for television, five educational public service announcements for radio, 

translated SMP brochures and PowerPoint; a volunteer management packet comprised of a 

volunteer application form, agreement, performance evaluation instrument, exit survey, and a 

one-form-fits all for volunteer activity reporting. 




Project Title: Idaho Senior Medicare Patrol (SMP) Capacity Building Project 




341 W Washington St 

PO Box 83720 


Contact: 

Donna Denny 

Tel. (208) 577-2854 

Email: donna.denney@aging.idaho.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $88,750 


As the current Senior Medicare Patrol (SMP) grantee, the Idaho Commission on Aging 

(ICOA) is supportive of the one-year SMP Capacity Building Grant offered by the 

Administration on Aging (AoA) and Centers for Medicare and Medicaid Services (CMS). The 

goal of this one-year award is to provide additional resources to reach more Medicare and 

Medicaid beneficiaries, their families and caregivers, with the message of fraud prevention 

and identification through enhanced efforts to increase and support the volunteer workforce 

required to expand outreach and education efforts throughout the state. The objectives are: 

1) to expand and enhance the SMP project’s volunteer force; and 2) to expand SMP outreach 

and education to Medicare beneficiaries, families and caregivers statewide. The expected 

outcomes of this SMP project are: 1) increased awareness of the SMP program; 2) 

increased number of volunteers; and 3) increased sub-contracts in a number of local 

community-based organizations to assist with outreach to minorities. The products include a 

final report; a website, and increased numbers of events and training hours in the data 

reporting system SMARTFACTS. 




Project Title: Illinois Senior Medicare Patrol Program 



AgeOptions 

1048 Lake St. 

Oak Park, IL 60301 

Contact: 

Anne Posner 

Tel. No. (708) 383-0258 

Email: anne.posner@ageoptions.org 

AoA Project Officer: Amy Wiatr-Rodriguez 

Fiscal 

Year 

Funding 

Amounts 









Total $300,000 


AgeOptions supports the one-year Health Care Fraud Prevention Program Expansion and 

SMP Capacity Building project. The goals are to expand outreach/public awareness of SMP; 

to increase and improve partnerships for the SMP program; to increase; to increase capacity 

of SMP volunteer program; and to enhance program capacity for management of beneficiary 

inquiries/complaints and project performance. The objectives are: 1) to expand targeted 

outreach to vulnerable beneficiaries; enhance depth and scope of education for beneficiaries 

statewide; explore new and innovative media/public awareness activities; 2) to collaborate 

with key partner organizations; develop new partnerships; enhance interface with CMS, CMS 

contractors, and law enforcement; 3) to expand and enhance the SMP Project's volunteer 

work force; enhance volunteer screening, training, and monitoring; and 4) to expand SMP 

ability to manage beneficiary inquiries and complaints in a timely, professional manner; 

enhance SMP capacity for performance management. The expected outcomes of this 

project include: 1) increased outreach; 2) increased number of beneficiary complaints, 

development of new partnerships with law enforcement, TRIAD groups, and senior housing 

service coordinators; and 3) increased volunteer involvement. Products from this project will 

include educational materials on specific fraud topics (presentations, tip sheets, press 

releases), materials in non-English languages, and resources related to volunteer program 

management. 




Project Title: Senior Medicare Patrol (SMP) Project 



Indiana Association of Area Agencies on Aging 

Education Institute 

4755 Kingsway Dr. Suite 402 


Contact: 

Kristan LaEace 

Tel. (317) 205-9201 

Email: klaeace@iaaaa.org 


Fiscal 

Year 

Funding 

Amounts 









Total $150,000 


Indiana Senior Medicare Patrol's (IN-SMP) project goal is to enhance its capacity to deliver 

statewide education and training on Medicare fraud prevention. The objectives are: 1) to 

enhance capacity to provide information on fraud, errors and abuse; 2) to engage new 

partners to collaborate and share information with beneficiaries; 3) to recruit, train and 

maintain additional volunteer coordinators to further outreach efforts; and 4) to initiate a 

statewide volunteer recruitment media campaign. The expected outcomes are: 1) an 

increase in volunteer coordination capacity; an increase in the number of active volunteers 

(including Spanish-speaking volunteers); 2) an increase in the number of efforts performed by 

volunteers; 3) an increase in the number of overall outreach efforts; 4) an increase in the 

number of fraud cases reported to the Area Agencies on Aging (AAAs), 5) an increase in the 

number of one-on-one counseling sessions; and 6) increased media exposure for IN-SMP. 

Products include media releases; articles targeting Medicare beneficiaries; new outreach 

materials targeting Hispanic populations; new outreach materials targeting rural populations; 

media publications and broadcasts targeting Hispanic and rural populations; and a final 

report. 




Project Title: Iowa Senior Medicare Patrol Expansion 



Hawkeye Valley Area Agency on Aging 

2101 Kimball Ave, Suite 320 

P O Box 388 

Waterloo, IA 50704-0388 

Contact: 

Shirley Merner 

Tel. (319) 272-2244 

Email: smerner@hvaaa.org 


Fiscal 

Year 

Funding 

Amounts 









Total $100,000 


Hawkeye Valley Area Agency on Aging (HVAAA) will expand the capacity of Iowa Senior 

Medicare Patrol (SMP) through efforts of current sub-contractors, Iowa's Area Agencies on 

Aging (AAAs) and the Iowa Center on Health Disparities (ICHD) and expand our partnership 

with the Iowa Department of Public Health (IDPH) to include diabetes educators statewide. 

The goal is to inspire a "call to action" attitude among Medicare beneficiaries and caregivers 

by using a fresh approach to deliver the SMP message, while expanding outreach, education 

and complaint resolution through an increased number of volunteers. The objectives are: 1) 

to expand and enhance our volunteer workforce; 2) to expand outreach and education more 

comprehensively statewide; 3) to increase inquiries received and expand our ability to 

manage complaints; 4) to enhance capacity to manage performance; and 5) to disseminate 

our technique, successes and challenges to interested audiences. The expected outcomes 

are: 1) an increased professionally managed and supported volunteer workforce; 2) an 

increase in the amount of funds recovered; and 3) an increased use of Iowa SMP services by 

Medicare beneficiaries and caregivers. Products will include training toolkits; presentations to 

professionals; and reports. 




Project Title: 2010 Kansas Senior Medicare Patrol Supplemental grant 




503 S Kansas Ave 


Contact: 

Tina Langley 

Tel. (785) 296-5222 


AoA Project Officer: Amelia R. Wiatr 

Fiscal 

Year 

Funding 

Amounts 









Total $100,000 


The Kansas Department on Aging (KDOA) is undertaking a Senior Medicare Patrol (SMP) 

capacity-building project to expand and enhance the Kansas SMP volunteer corps. Kansas 

SMP will develop new partnerships with community-based organizations across the state to 

recruit and train new volunteers, with an emphasis on reaching rural areas and Spanishspeaking 

communities. The goal of the project is to build the capacity of the SMP by 

recruiting, training and maintaining a network of active volunteers that covers every county in 

Kansas. The objectives are: 1) to hire a full-time, bi-lingual Volunteer Coordinator to recruit, 

train and manage volunteers; 2) to recruit "unaffiliated" volunteers who can provide services 

in the community; 3) to develop an infrastructure that will streamline the reporting/referral 

process; and 4) to establish six Regional Volunteer Coordinator positions to continue 

volunteer recruitment, training and recognition after this grant ends. Expected outcomes are: 

1) an increase in the statewide availability of trained, active volunteers; 2) an increase in the 

number of unaffiliated volunteers; 3) an increase in the use of the new SMP Partner web 

page; 4) an increase in volunteer activity; and 5) an increase in public awareness of fraud. 

Products will include a new SMP Partner web page; recruitment and training materials; OIG 

reports generated through SMARTFACTS; and narrative reports detailing strategies and 

results. 




Project Title: Senior Medicare Patrol - Capacity Building 



Louisville/Jefferson County Metro Government 

Attn: Public Health and Wellness 

527 West Jefferson Street 

Louisville, KY 40202 

Contact: 

Betty Adkins 

Tel. No. (502) 574-2003 

Email: betty.adkins@louisvilleky.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $150,000 


The grantee, Kentucky Senior Medicare Patrol (SMP), supports this one-year Capacity 

Building Grant in collaboration with its current statewide subcontractors. The goal of the 

project is to increase and support SMP volunteers for the purpose of expanding outreach and 

education regarding healthcare fraud and abuse throughout the state. The objectives are: 1) 

to recruit, train, manage, and support 105 additional SMP volunteers; 2) to expand outreach 

and education to beneficiaries throughout Kentucky, targeting limited English-speaking 

populations, rural communities, and beneficiaries living in poverty; 3) to develop the capability 

to manage beneficiary inquiries and issues in a timely and professional manner; and 4) to 

enhance the capacity for performance management. The expected outcome of this project is 

that there will be an increase in the number of beneficiaries that: 1) become better educated 

consumers of their healthcare system; 2) understand the importance of reviewing Medicare 

Summary Notices and Explanation of Benefits, and; 3) are empowered to prevent healthcare 

fraud and preserve the financial integrity of Medicare and Medicaid. Products from this 

project will be: 1) a final report including a program evaluation; 2) a new state-wide toll-free 

telephone number staffed by the Louisville Metro SMP; 3) additional materials and resources 

to distribute to beneficiaries; and 4) increased media exposure. 




Project Title: Louisiana Senior Medicare Patrol Project - Fraud Prevention 

Program 



eQ Health Solutions, Inc. 

8591 United Plaza Blvd., Suite 270 

Baton Rouge, LA 70809-7007 

Contact: 

Tricia Canella 

Tel. No. (225) 248-7064 

Email: tcanella@eqhs.org 

AoA Project Officer: Derek B. Lee 

Fiscal 

Year 

Funding 

Amounts 









Total $379,433 


The goal of the Louisiana Senior Medicare patrol (SMP) is to reach Medicare beneficiaries to 

educate them to reduce fraud, errors and abuse in the Medicare system through more direct 

and effective collaboration with the Department of Justice Health Care Fraud Prevention and 

Enforcement Action Team (HEAT) Strike Force unit. The objectives are: 1) to expand 

current organizational capacity to recruit, train, support, and manage SMP volunteers; 2) to 

increase the number of partners and involving them in appropriate activities; 3) to expand 

program coverage and outreach to a statewide level; 4) to strengthen outreach to 

beneficiaries at greatest risk; and 5) to develop a more direct and effective collaboration with 

Louisiana's HEAT Strike Force. The expected outcomes are: 1) an increase in SMP 

activities from 27 parishes to 64 parishes; 2) an increase in senior volunteers from 15 to 50; 

3) establishment of three Community SMP Leaders; 4) educated 9,000 beneficiaries; 5) 

increased number of members of the Medicare Fraud Alert system; and 6) an increased 

involvement with Louisiana's HEAT Strike Force. Products will include: beneficiary pre-and 

post-survey; electronic training manual; and training materials. 




Project Title: Maine Senior Medicare Patrol Capacity Building Grant 





32 Blossom Lane, SHS 11 

August, ME 04333-0011 

Contact: 

Kathy Poulin 

Tel. No. (207) 287-9206 


AoA Project Officer: Gene Brown 

Fiscal 

Year 

Funding 

Amounts 









Total $88,750 


Maine's DHHS Office of Elder Service (OES), supports this Capacity Building Grant for 

Maine’s Senior Medicare Patrol (SMP) in collaboration with Maine’s five area agencies on 

aging (AAAs), Legal Services for the Elderly (LSE) and related partners. The goal of the 

project is to increase awareness and reporting of healthcare fraud statewide. The approach 

is to obtain additional volunteers and reorganize existing staff and volunteer responsibilities to 

maximize outreach and reporting. The objectives are: 1) to expand partnerships with law 

enforcement agencies, Center for Medicare and Medicaid Services and other partners; 2) to 

expand the number of trained volunteers statewide and their role in researching and reporting 

fraud complaints; 3) to increase the support for recruitment, training, management, and 

retention of volunteers; and 4) to increase outreach and education efforts with beneficiaries, 

their families, caregivers, and providers statewide. Expected outcomes of this project are: 1) 

the creation of a Special Project Coordinator position dedicated to enhancing volunteer 

workforce development and management to expand the capacity to investigate healthcare 

fraud in Maine; 2) an increase in recruiting, training, managing, and retaining volunteers; 3) 

the creation of volunteer Subject Matter Experts (SMEs) to investigate and report healthcare 

fraud; 4) an increase in the reporting of healthcare fraud cases; and 5) an increase in 

outreach to consumers and providers on identifying and reporting healthcare fraud. 

Anticipated products from this project include additional Personal Health Journals; television 

ads; promotional items that include the SMP message and the statewide, toll-free phone 

number; new brochures; new outreach presentations for consumers and providers; reports to 

AoA; and abstracts and presentations for regional and/or national SMP conferences. 




Project Title: Senior Medicare Patrol Projects 




301 West Preston St., Suite 1007 


Contact: 

Gloria G. Lawlah 

Tel. No. (410) 767-1271 

Email: dms@ooa.state.md.us 

AoA Project Officer: Barry F. Klitsberg 

Fiscal 

Year 

Funding 

Amounts 









Total $300,000 


The Maryland Department of Aging (MDoA) will build upon current lessons learned and best 

practices that include centralized outreach, marketing and volunteer recruitment approaches, 

enhanced and specialized trainings, and expansion of strategic partnerships. The goal of this 

project is to empower Maryland seniors through increased awareness and training and to 

protect them from the economic and health related consequences associated with Medicare 

and Medicaid fraud, error and abuse. The objectives are: 1) to increase volunteer 

recruitment to expand and enhance the volunteer workforce; 2) to expand outreach and 

educational opportunities to beneficiaries statewide: 3) to expand the program statewide, 4) 

to expand the program's ability to manage beneficiary inquiries and complaints efficiently; 

and 5) to enhance the capacity for performance management. Expected outcomes include: 

1) increased jurisdictions statewide; 2) increased number of volunteers; 3) increased number 

of beneficiaries and their caregivers counseled; 4) increased media outreach; 5) increased 

number of inquiries and concerns; and 6) increase of counselors at local level to manage 

reporting mechanisms available to trained volunteers. Products to be developed include a 

marketing and outreach report and evaluation; training video and DVD files, flyers, 

announcements, and a training kit. 




Project Title: Expansion of Massachusetts Senior Medicare Patrol Program 



Elder Services of the Merrimack Valley, Inc. 

360 Merrimack Street. Building #5 

Lawrence, MA 01843 

Contact: 

Dayna Brown 

Tel. No. (978) 946-1368 

Email: Dbrown@esmv.org 

AoA Project Officer: Barry Michaels 

Fiscal 

Year 

Funding 

Amounts 









Total $299,885 


The Elder Services of the Merrimack Valley, Inc. (ESMV) supports the Massachusetts Senior 

Medicare Patrol Program (MA SMP) in this one-year grant to develop innovative health care 

fraud prevention activities. The goal of the of the program is to expand its capacity to more 

effectively reach a higher number of Medicare and Medicaid beneficiaries, their families and 

caregivers with information on how to protect their personal information, detect any 

irregularities with their medical bills, Medicare Summary Notices, Explanation of Benefits and 

report any discrepancies. The objectives are: 1) to expand outreach and education to 

beneficiaries statewide; 2) to work with existing SMP grantees to build their capacity to 

increase outreach and education efforts as well as volunteer recruitment from respective 

immigrant communities; 3) to develop and increase additional collaborations with partner 

organizations, including enhance interface with Center for Medicare and Medicaid Services 

(CMS), CMS Contractors and the Office of Inspector General (OIG); 4) to expand MA SMP 

volunteer corps by improving and enhancing statewide SMP program volunteer recruitment 

and management; 5) to expand ability to manage beneficiary inquiries and complaints in a 

timely professional manner; and 6) to implement new healthcare fraud media/public 

awareness campaign. The expected outcomes are: 1) increased outreach and education 

efforts to beneficiaries; 2) increased collaborations with partner organizations; 3) increased 

number of MA SMP volunteers; and 4) increased internal ability to manage beneficiary 

inquiries and complaints in a timely professional manner. Products will include materials for 

public awareness media campaign and evaluation and reports. 




Project Title: Capacity Expansion of Michigan AP Senior Medicare Patrol Project 



Michigan Medicare/Medicaid Assistance Program, Inc. (MMAP) 

6105 W. St. Joseph Hwy. Suite 204 


Contact: 

Jo Murphy 

Tel. No. (517) 886-1242 

Email: jo@mmapinc.org 

AoA Project Officer: Sam J. Gabuzzi 

Fiscal 

Year 

Funding 

Amounts 









Total $380,000 


The goal of the Michigan Medicare/Medicaid Assistance Program (MMAP) Health Care Fraud 

Prevention Program Expansion and Senior Medicare Patrol (SMP) Capacity Building Project 

(MMAP SMP Expansion Project) is to enhance the efforts of Michigan’s SMP Project to 

increase prevention, detection, and reporting of Medicare fraud and abuse and reach 

beneficiary populations statewide and specifically in the geographical location of the Health 

Care Fraud Prevention and Enforcement Action Team (HEAT) Joint Strike Force. MMAP, 

Inc. partners with the 16 Area Agencies on Aging (AAA) in Michigan. The AAAs provide SMP 

counseling, and community outreach through a workforce of MMAP volunteers. The AAAs 

recruit, manage, and provide ongoing training and support to their MMAP volunteers. MMAP, 

Inc. and the AAAs will undertake the following objectives to accomplish the project goal: 1) to 

expand awareness of health care fraud and enhance the role of the SMP as a working 

partner in the HEAT Joint Strike Force geographical area, and (2 to expand the capacity of 

Michigan’s SMP Project to recruit, manage, and support MMAP/SMP volunteers, and utilize 

these volunteers to effectively expand SMP outreach to beneficiaries in local communities. 

The expected outcomes will be: 1) increased referrals to MMAP from Medicare beneficiaries, 

their family members, and caregivers; state and local partners; and professional 

organizations; and 2) increased number of qualified volunteers who conduct community 

education and outreach events and manage beneficiary inquiries and complaints in a 

professional manner. Products to be produced include customized public education and 

outreach materials including: sample press releases, flyers, brochures, and outreach 

presentations; summary of innovative best practices in reaching vulnerable, at-risk 

populations; and an internet-based SMP training and certification module. 




Project Title: Minnesota's Senior Medicare Patrol Capacity Building Grant 





PO Box 64976 

St. Paul, MN 55164-0976 

Contact: 

Krista Boston 

Tel. (651) 431-7415 


AoA Project Officer: Katheen Votava 

Fiscal 

Year 

Funding 

Amounts 









Total $150,000 


The grantee, Minnesota Board on Aging, supports this one year Senior Medicare Patrol 

(SMP) Capacity Building grant in partnership with the Area Agencies on Aging in Minnesota. 

The goal for the grant project is to expand the capacity of the SMP project. Program 

objectives include: 1) to expand Minnesota SMP outreach and education to beneficiaries 

statewide with emphasis on the Spanish-speaking and rural populations, 2) to expand and 

enhance the Minnesota SMP volunteer workforce with target recruitment of Spanish-speaking 

volunteers and volunteers in rural areas, 3) to expand the Minnesota SMP ability to manage 

beneficiary inquires and complaints in a timely, professional manner, 4) to enhance SMP 

capacity for performance management. The intended outcomes of this project are: 1) 

increased number of rural and Spanish-speaking beneficiaries in Minnesota who are aware of 

fraud, error and abuse and know to identify and report potential issues to the Senior LinkAge 

Line®, 2) increased number of rural and Spanish-speaking volunteers who are able to 

provide assistance to hard-to-reach populations in Minnesota, 3) Senior LinkAge Line® staff 

and volunteers possess the skills and confidence to provide comprehensive health insurance 

counseling and education as it pertains specifically to health care fraud, error and abuse. 

Products will include: an episode within the MBA and Twin Cities Public Television series 

"Getting There" focused on health care fraud, error and abuse; PSAs; an updated Minnesota 

SMP website located within the Minnesota Board on Aging website; and an updated Senior 

Surf Day manual used in education sessions. 




Project Title: Missouri Senor Medicare Patrol Expansion Project 



District III Area Agency on Aging 

PO Box 1078 

Warrensburg, Missouri 64093 

Contact: 

Diana Hoemann 

Tel. (660) 747-3107 

Email: dhoemann@goaging.org 

AoA Project Officer: Kathleen Votava 

Fiscal 

Year 

Funding 

Amounts 









Total $150,000 


The Missouri Senior Medicare Patrol (SMP) Expansion Project is a one-year project with the 

goals of expanding the capacity of the Missouri SMP project to recruit, screen, train, manage 

and support an increased number of SMP volunteers, and utilize these volunteers to 

effectively expand SMP outreach to beneficiaries in local communities in a more 

comprehensive manner throughout the state. The objectives of the project are: 1) to expand 

and enhance the SMP project’s volunteer workforce; 2) to expand SMP outreach and 

education to beneficiaries statewide; 3) to expand SMP ability to manage beneficiary inquiries 

and complaints in a timely and professional manner; and (4 to enhance SMP capacity for 

performance management. Expected outcomes of the project include: 1) a 75% increase in 

active SMP volunteers who report outreach and education activity; and ) 75% of SMP 

volunteers will continue their commitment to the program for another year. The major product 

that will result from this project is an easily replicable SMP Outreach Campaign for volunteers 

to complete. 




Project Title: Senior Medicare Patrol Capacity Building Grant 



Mississippi Department of Human Resources 

Post Office Box 352 


Contact: 

Dan George 

Tel. (601-359-4929) 

Email: Danny.George@mdhs.ms.gov 

AoA Project Officer: Joyce R. Robinson-Wright 

Fiscal 

Year 

Funding 

Amounts 









Total $100,000 


The Mississippi Department of Human Services Division of Aging and Adult Services 

(MDHS/DAAS) is collaborating with Mississippi's ten Area Agencies on Aging, Mississippi 

SHIP and other key partners. The project goal is to enhance the Senior Medicare Patrol 

(SMP) efforts to increase and support the volunteer workforce required to expand outreach 

and education efforts throughout the state. The objectives are: 1) to expand and increase 

the volunteer workforce by recruiting, training, managing and supporting outreach to retired 

professionals and the general population, who, as SMP volunteers, provide broader program 

coverage in underserved communities; 2) to expand SMP outreach and education to 

beneficiaries statewide; 3) to expand SMP ability to manage beneficiary inquiries in a 

professional and timely manner; and 4) to enhance SMP capacity for performance 

management. The expected outcomes are: 1) expanded volunteer network to educate and 

assist seniors in previously underserved areas; 2) new media outreach; 3) increased 

numbers educated to monitor Medicare statements for error and to call for assistance; and 4) 

increased resolution to calls and complaints. Products include a final evaluation report; data 

on volunteer and training sessions; new SMP fraud-fighting informational/educational 

literature designed for underserved beneficiaries with diverse levels of literacy. 




Project Title: Montana Healthcare Waste, Fraud and Abuse Volunteer 

Expansion Project 



Missoula Aging Services 

337 Stephens Ave 

Missoula, MT 59801 

Contact: 

Renee Labrie-Shanks 

Tel. (406) 728-7682 

Email: rlabrie@missoulaagingservices.org 

AoA Project Officer: Susan A. Raymond 

Fiscal 

Year 

Funding 

Amounts 









Total $50,000 


Senior Medicare Patrol Montana is eager to expand on and enhance the project’s volunteer 

work force. The goal of this expansion is to add volunteers who remain active in the SMP 

program once trained through better volunteer management. The intention is to train those 

volunteers who are interested in responding to complaints and investigating concerns in a 

timely manner and improve their ability to thoroughly investigate complex inquiries. The 

objectives are: 1) to designate SMP Montana staff time and travel to provide one-on-one 

training to create local volunteer coordinators with the participating partners; 2) to expand 

sub-contracts using monetary incentives for maintaining active volunteers; and 3) to create a 

specialized volunteer training model based on select current volunteers that can be 

duplicated throughout the state that will cater to volunteers with the ability to work on complex 

cases. The expected outcomes will be: 1) to reach the goal of 100 active volunteers 

statewide, an increase of 50 new volunteers and 25 re-activated volunteers; 2) current 

volunteers and 25 new volunteers will increase their ability to investigate complaints and 

provide appropriate referrals; 3) increase SMP effort of Montana’s Program Manager from 

part-time to full-time; and 4) final reports will reflect an increase in complex inquiries received 

and beneficiaries reached. The products from this project are a final report, a webinar based 

volunteer coordinator training that can be duplicated and shared nationally; articles for 

publication; enhanced volunteer training to specifically cover complex inquiries and casework. 




Project Title: Expand the capacity of the Senior Medicare Patrol Project 




Division of Medicaid and Long Term Care 

P.O. Box 95026 

Lincoln, NE 68509-5026 

Contact: 

Madhavi Bhadbhade 

Tel. No. (402) 471-2309 

Email: madhavi.bhadbhade@nebraska.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $88,750 


The goal of the Nebraska Senior Medicare Patrol (SMP), a project of the Nebraska 

Department of Health and Human Services (DHHS), State Unit on Aging (SUA), is to expand 

the SMP outreach and education to beneficiaries statewide by expanding and enhancing the 

SMP volunteers’ network that will be trained in conducting outreach and education, focusing 

on areas that have been underserved. The objectives include: 1) expand SMP Outreach and 

Education to beneficiaries in all counties in the state; 2) expand and enhance the project’s 

volunteer workforce by ensuring adequate SMP staffing levels to effectively recruit, train, 

support and manage the volunteer workforce; 3) develop a Media Toolkit and outreach 

materials for volunteers to use to increase beneficiary awareness about the SMP Program; 4) 

enhance and solidify state and local partnerships with organizations such as AARP, State 

Health Insurance Information Program, Rural Health Organizations, and Area Agencies on 

Aging (AAAs); and 5) Target training and education to isolated areas and to minorities. The 

outcomes of the project include: increased awareness of healthcare fraud, error, waste and 

abuse throughout the state, especially in areas that are underserved; increase volunteer 

workforce in additional communities and areas with large population; and increased SMP 

visibility statewide using a media toolkit, website enhancement and enhancing partnerships. 

The products of the project will include: a media tool kit and other materials such as Public 

Service Announcements, enhanced website, promotional outreach items, bill boards and print 

advertisements. 




Project Title: Health Care Fraud Prevention Program Expansion and Senior 

Medicare Patrol Capacity Building Grants 



Nevada Office of the Attorney General 

555 East Washington Ave., #3900 

Las Vegas, NV 89101 

Contact: 

Jo Anne Embry 

Tel. No. (702) 486-3154 

Email: jembry@ag.nv.gov 

AoA Project Officer: Dennis E. Dudley 

Fiscal 

Year 

Funding 

Amounts 









Total $284,268 


The goal of the Nevada Senior Medicare Patrol (NV SMP) is to develop innovative health 

care fraud prevention activities to expand its capacity to recruit, train, manage and support an 

increased number of volunteers to handle the increased number of inquiries generated by 

expansion efforts. The objectives are: 1) to target statewide development; 2) to develop new 

collaborations with law enforcement and non-profit organizations; 3) to enhance interface with 

Center for Medicare and Medicaid Services (CMS) Los Angeles Field Office and CMS 

contractors; 4) to develop innovative approach and education through collaboration with law 

enforcement and non-profit organizations; and 5) to target hard-to-reach, underserved, 

minority populations in Northern Nevada with messages through the media and with 

appropriate materials. The expected outcomes are: 1) increased consumer awareness of 

heath care fraud control mechanisms; 2) increased base of volunteers; 3) enhanced training 

and consistent updates for existing volunteers; and 4) enhanced partnerships with law 

enforcement agencies. Products include training materials and Public Service 

Announcements. 




Project Title: Senior Medicare Patrol (SMP) Capacity Building Grant 




Bureau of Elderly and Adult Services 



Contact: 

Karol Demon 

Tel. (603) 271-4925 

Email: kdermon@dhhs.state.nh.us 


Fiscal 

Year 

Funding 

Amounts 









Total $88,750 


The New Hampshire Department of Health and Human Services' Bureau of Elderly and Adult 

Services is the grantee for the New Hampshire Senior Medicare Patrol (SMP) Program. The 

goal for this one-year grant is to expand the capacity of the state SMP project to recruit, train, 

manage, and support an increased number of SMP volunteers to handle the increased 

number of inquiries generated by expansion efforts. The objectives are: 1) to create an 

active, knowledgeable volunteer network; 2) to establish a volunteer management team to 

recruit, train, and retain a pool of volunteers for the entire state; 3) to support primary point for 

investigating consumer complaints, resolving complex billing issues, and referring potential 

fraud and abuse cases to the appropriate Medicare contractor; and 4) to develop 

partnerships to focus on vulnerable populations. The expected outcomes are: 1) an 

increased number of knowledgeable volunteers; 2) improved quality and quantity of inquiries; 

and 3) enhancement of SMP recognition and performance measures. Products will include 

media materials, newsletters, and Public Service Announcements. 




Project Title: Senior Medicare Patrol of New Jersey 



Jewish Family and Vocational Services of Middlesex County 

32 Ford Ave., 2 nd Fl. 

Milltown, NJ 08850-1532 

Contact: 

Charles Clarkson 

Tel. No. (732) 777-1940 

Email: CharlesC@jfvs.org 


Fiscal 

Year 

Funding 

Amounts 









Total $300,000 


The goal of the New Jersey Senior Medicare Patrol (NJ SMP) under this capacity building 

grant is to use its expertise to expand outreach to Medicare/Medicaid beneficiaries. The 

objectives are: 1) to partner with multiple agencies not currently NJ SMP partners and 

professionals in the aging services network and other areas to promote and expand 

awareness of Medicare/Medicaid fraud, waste and abuse; 2) to develop and disseminate 

educational materials about Medicare/Medicaid fraud, waste and abuse to targeted 

populations; 3) to expand SMPNJ outreach through the use of media events, including the 

use of the SMP Resource Center's toolkit; and 4) to serve as consumer advocate to resolve 

billing disputes and errors and to receive, respond to, and follow-up on complaints about 

suspected fraud, waste and abuse, and make referrals to appropriate agencies. The 

expected outcomes are: 1) an increase in older adults that will become knowledgeable about 

fraud, waste and abuse in the Medicare/Medicaid programs; 2) an increase in older adults 

that review their Medicare Summary Notice; 3) an increase in older adults that take the 

necessary steps to call their healthcare providers to correct billing disputes and errors; and 4) 

an increase in older adults that report suspected cases of fraud, waste and abuse. Products 

will include training materials in English and Spanish and materials for media distribution. 




Project Title: New York State - HEAT Grant 





Albany, NY 12223-1251 

Contact: 

Marcas Harazin 

Tel. No. (518) 473-5177 


AoA Project Officer: Barry F. Kitsberg 

Fiscal 

Year 

Funding 

Amounts 









Total $430,000 


The New York State Office for the Aging (NYSOFA), working with the Health Care Fraud 

Prevention and Enforcement Force Action Team (HEAT) Strike Force, National Government 

Services (NGS), three Area Agencies on Aging (AAAs) and 59 Health Insurance, Information 

Counseling and Assistance Program/Senior Medicare Patrols (HIICAP/SMPs) statewide, will 

reach more Medicaid and Medicare beneficiaries. Goals are: 1) establish effective working 

partnership with the Brooklyn HEAT Strike Force and 2) expand the capacity of the 

HIICAP/SMP volunteer network to educate consumers in prevention of health care fraud. 

Objectives are: 1) convene a SMP Project Management Group with HEAT Strike Force 

members that meets regularly to review goals and objectives and discuss issues encountered 

in achieving them; 2) develop targeted consumer fraud and abuse media campaign; 3) target 

specific interventions to high need areas; 4) develop monthly one hour live radio talk show in 

the greater New York City area; 5) develop and test turn-key training program for SMP-only 

and HIICAP/SMP volunteers; 6) purchase and distribute fraud and abuse education and 

outreach materials statewide. The expected outcomes include: 1) establishing coordination 

with the HEAT Strike Force; 2) expanded reach to vulnerable and at-risk Medicare 

populations; 3) increased awareness of fraud and abuse among Medicare beneficiaries; 4) 

increased reporting of fraud and abuse through HIICAP/SMPs in three geographic areas; and 

5) increased capacity for all our HIICAP/SMPs to recruit, train and effectively use SMP-only 

volunteers. Products include brief, easy-to-use volunteer training program for all 59 

HIICAP/SMPs in NYS; targeted media campaign including monthly one-hour live radio show; 

printed fraud and abuse marketing materials; and a final report. 




Project Title: North Carolina Senior Medicare Patrol Program 



North Carolina Department of Insurance 

11 South Boylan Avenue 


Contact: 

Carla Obiol 

Tel. No. (919) 807- 6900 

Email: carla.obiol@ncdoi.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $300,000 


The Seniors' Health Insurance Information Program (SHIIP) of the North Carolina Department 

of Insurance (DOI) will expand the capacity of the North Carolina Senior Medicare Patrol 

Program (NCSMP) to recruit, train, manage, and support an increased number of SMP 

volunteers to handle the increased number of inquiries generated by expansion efforts. The 

goal of the project is to enhance NCSMP efforts to reach a larger number of Medicare 

beneficiaries and caregivers with the SMP message of fraud prevention education 

awareness. The objectives are to: 1) provide statewide educational efforts targeting 

vulnerable and at-risk beneficiaries; 2) increase healthcare fraud prevention partnerships and 

collaborations with local, state and federal law enforcement agencies; 3) enhance 

coordination of NCSMP program activities and efforts with Regional Center for Medicare and 

Medicaid Services Office and Contractors; 4) develop statewide media/public awareness 

activities to expand SMP program messaging regarding health care fraud prevention 

education; 5) expand the capacity of NCSMP to recruit, screen, train, manage and support an 

increased number of NCSMP Volunteer Specialists statewide and program staffing to 

accomplish the task. The expected measurable outcome of this project is to successfully put 

"boots on the ground" by expanding the statewide SMP coordinated effort centered on 

practical steps to protect Medicare benefits from identity theft, detect errors on health care 

statements by reviewing for accuracy and the source for reporting suspected healthcare 

fraud. These efforts will be recorded in Smart Facts and analyzed for program expansion 

effectiveness. The products from this program are: 1) written AoA progress, financial and 

OIG reports and 2) educational and training materials and media efforts. 




Project Title: North Dakota Senor Medicare Patrol Supplement 2010 



Minot State University 

North Dakota Center for Persons with Disabilities 

500 University Avenue West 

Minot, ND 

Contact: 

Linda Madson 

Tel. (701) 858-3424 

Email: linda.madsen@minotstateu.edu 


Fiscal 

Year 

Funding 

Amounts 









Total $50,000 


The Senior Medicare Patrol (SMP) project in North Dakota will collaborate with the North 

Dakota State Health Insurance Counseling (ND SHIC), Retired Service Volunteer Corps 

(RSVP) and Lutheran Social Services of North Dakota (LSSND) to increase volunteers and 

expand outreach and education efforts throughout the state to seniors in underserved 

counties and non-English speaking New Americans. The goal is to expand the capacity of 

the SMP project the state. The objectives of North Dakota SMP are to: 1) expand and 

enhance the SMP project’s volunteer work force, 2) expand SMP Outreach and Education to 

beneficiaries statewide, 3) expand SMP ability to manage beneficiary inquiries and 

complaints in a timely, professional manner, and 4) enhance SMP capacity for performance 

management. The expected outcome is greater public awareness of potential Medicare 

errors and fraud. Products will include a final report with evaluation results; an accessible 

website; written materials translated for non-English speaking populations; paper and 

electronic presentations; and professional articles. All materials will be made available in 

alternative formats upon request. 




Project Title: Health Care Fraud Prevention Program Expansion and 

Senior Medicare Patrol Capacity Building 




7162 Reading Rd., suite 1150 


Contact: 


Tel. No. (513) 458-5506 



Fiscal 

Year 

Funding 

Amounts 









Total $299,828 


Pro Seniors proposes to expand its Ohio Senior Medicare Patrol (SMP) project to accomplish 

the following goals: 1) to increase public awareness of health care fraud and the role of Ohio 

SMP in combating this crime and 2) to enhance the capacity of Ohio SMP to support an 

increased number of volunteers thereby expanding outreach to beneficiaries throughout 

Ohio. Objectives include the following: 1) to expand SMP outreach and education, focusing 

on high fraud and underserved areas and vulnerable, at-risk and limited English-speaking 

beneficiaries; 2) to increase strategic collaboration with law enforcement and other partners; 

3) to enhance interface with the Center for Medicare and Medicaid Services (CMS) and CMS 

contractors to improve referrals; 4) to increase public awareness of health care fraud and 

Ohio SMP through outreach and education and a media campaign; 5) significantly increase 

the number of Ohio SMP volunteers, including recruiting a dual-language volunteer; 6) to 

enhance Ohio SMP program staffing to support increased number of volunteers; and 7) to 

expand capacity to respond to beneficiary inquiries and complaints. The expected outcomes 

are: 1) Ohio SMP will increase its number of volunteers by 50%, recruiting and training 33 

additional volunteers; 2) Ohio SMP will provide at least one outreach/education activity in 

each of the 38 counties where our message has not yet been provided; 3) at least eight 

outreach/education activities will be offered to limited English-speaking populations; and 

media coverage will be used in each of the five regions of the state. Products will include: 

personal healthcare journals and brochures in appropriate languages. 




Project Title: Health Care Fraud Prevention Program Expansion and Senior 

Medicare Patrol Capacity Building Grant 



Oklahoma Insurance Department 

Senior Health Insurance Information Program Division 

Five Corporate Plaza 

3625 NW 56th Street, Suite 100 


Contact: 

Lisa B. Gober 

Tel. (401) 521-6632 

Email: lisa.gober@oid.ok.gov 

AoA Project Officer: Lisa J. Theirl 

Fiscal 

Year 

Funding 

Amounts 









Total $100,000 


The grantee, Oklahoma Senior Medicare Patrol (SMP), supports a one-year collaborative 

initiative with the Centers for Medicare and Medicaid Services (CMS) and the Administration 

on Aging (AoA) with focus to expand and enhance the SMP project’s volunteer workforce, 

which will result in greater consumer healthcare fraud prevention and education. The goal of 

the project seeks to increase the number of Oklahoma Medicare and Medicaid beneficiaries 

who can identify health care fraud, report health care fraud and tell other seniors how to 

detect and prevent fraud in their communities. The objectives are: 1) to foster expanded and 

enhanced statewide program coverage; 2) improve beneficiary education and inquiry 

resolution for issues of health care fraud; 3) foster SMP national program visibility and 

consistency; 4) improve efficiency of SMP program while increasing results for both 

operational and quality measures; and 5) target training and education to isolated and hardto-reach 

populations. The expected outcomes of the project include: 1) increased numbers 

of seniors being trained as SMP volunteers; 2) increased number of outreach presentations 

being conducted to beneficiaries; and 3) increased one-on-one beneficiary contacts resulting 

from reporting of potential fraud. The products created for this project will include a new SMP 

brochure, fraud placemats, media Public Service Announcements and reporting documents 

on the outcome results of the project. 




Project Title: Oregon Senior Medicare Patrol 




Senior and Disabled Services 

3420 Cherry Ave NE, Suite 140 

Salem, OR 97303-5328 

Contact: 

Victoria L. Weld 

Tel. (503) 934-6068 

Email: victoria.l.weld@state.or.us 


Fiscal 

Year 

Funding 

Amounts 









Total $100,000 


The Oregon Department of Human Services, Senior and People with Disabilities Division 

(SPD) is Oregon's primary Senior Medicare Patrol (SMP) grantee. The primary goal is to 

effectively educate beneficiaries, increase organizational and service capacity by recruiting 

and training volunteers, and increase public awareness and participation by conducting 

outreach activities. The objectives are: 1) to employ media resources to increase public 

awareness, promote our services and recruit volunteers; 2) to develop or acquire support 

materials and technologies to effectually execute objectives; 3) to combine forces in multiagency 

outreaches that leverage resources and larger audiences; 4) to widen the SMP 

message to rural and Latino Oregonians, recruiting volunteers from each group (including bilingual 

Latinos); 5) to engage and motivate frontier populations to establish an effective, 

innovative system for frontier SMPs; and 6) to influence Latino societal views on Medicare 

fraud using cultural norms. Expected outcomes include: 1) increased recognition for SMP 

program; 2) increased contact with Latino and rural populations yielding more volunteers, 

some of them bi-lingual with the ultimate goal of establishing a Spanish speaking arm of 

SMP; and 3) an effective infrastructure designed to flex in capacity as we grow; greater 

expertise for tracking fraud, abuse or errors; and increase in services. Products include 

media kits; ad campaign components; volunteer brochures and handbills; and reports and 

evaluations as required. 




Project Title: Pennsylvania SMP - Senior Medicare Patrol Projects 



Center for the Rights and Interests of the Elderly 

100 South Broad Street, Suite 1500 


Contact: 

Diane Menio 

Tel. No. (215) 545-5728 

Email: menio@carie.org 


Fiscal 

Year 

Funding 

Amounts 









Total $300,000 


The goal of the Center for Advocacy for the Rights and Interests of the Elderly (CARIE) is to 

expand the PA-Senior Medicare Patrol's (SMP) statewide coverage through the use of 

volunteer peer educators and collaborations and partnerships, including the state Senior 

Health Insurance Information Program (SHIP - APPRISE) program by educating older adults 

and caregivers to recognize, detect, and report suspected health care fraud and abuse in the 

Medicare and Medicaid programs. The objectives are: 1) to develop innovations in outreach 

and education to Medicare and Medicaid beneficiaries statewide; 2) to collaborate with 

partner organizations; 3) to enhance interface with CMS and CMS contractors; 4) to develop 

new media/public awareness activities; 5) to expand and enhance the SMP project's 

volunteer workforce; 6) to expand ability to manage beneficiary inquiries and complaints in a 

timely, professional manner; and 7) to enhance capacity for performance management. The 

expected outcomes are: 1) increased number of beneficiaries reached (8,000-10,000); 

increased number of new volunteers trained (15-20); 2) increase in number of beneficiary 

complaints and subsequent referrals for investigation; 3) increased communication and 

strengthened relationships with CMS contractors; and 4) increase in number of education 

materials across the state. Products developed include outreach and educational materials 

in English and other languages, project newsletters, reports to AoA and the OIG, and 

giveaways with a fraud prevention message. 




Project Title: Puerto Rico Senior Medicare Patrol Capacity Building Project 



Puerto Rico Governor’s Office of Elderly Affairs 

P.O. Box 191179 

San Juan, PR 00919-1179 

Contact: 

Rosanna Lopez 

Tel. (787) 721-6121 



Fiscal 

Year 

Funding 

Amounts 









Total $100,000 


The Puerto Rico Senior Medicare Patrol (SMP) Capacity Building Project’s main goal is to 

enhance its capacity through recruitment of additional volunteers, an improved managerial 

capability for training and performance of staff and volunteers, and an extended community 

outreach and awareness initiative. Its objectives are: 1) to recruit 15 additional volunteers 

and one additional staff counselor; 2) to broaden the knowledge and competency of 

volunteers, 3) to enhance staff counselors capabilities for recruitment, training, support and 

management of volunteers; 4) to expand our ability to manage inquiries and complaints in a 

timely, professional manner; and 5) to extend outreach, education and training efforts to all 

municipalities and previously underserved communities. The expected outcomes include: 1) 

the recruitment and retention of 15 additional volunteers and one additional counselor; 2) 

increase proficiency in knowledge relevant to health care fraud; 3) limit turnover of volunteers 

to less than 10%; and 4) increase by 50% the number of simple and complex issues 

processed. Products to be available in clude a final report, educational materials in Spanish, 

and web-access to program information. 




Project Title: Rhode Island Senior Medicare Patrol Program 



Rhode Island Department of Elder Affairs 

74 West Rd, Hazard Building 


Contact: 

Aleatha Dickerson 

Tel. (401) 462-0931 

Email: adickerson@dea.ri.gov 

AoA Project Officer: Gene H. Brown 

Fiscal 

Year 

Funding 

Amounts 









Total $88,750 


The goal of the Rhode Island Senior Medicare Patrol (SMP) is to continue to provide a 

comprehensive, coordinated statewide information/referral system related to 

Medicare/Medicaid fraud, waste, and abuse. The primary goal for this project is to expand 

efforts to provide SMP outreach/education throughout Rhode Island. The objectives are: 1) 

to provide resources and training to ensure volunteers are fully equipped to train present and 

new volunteers with the most current, updated SMP information; 2) to provide targeted 

outreach to traditionally underserved, culturally diverse and ethnic racial communities; and 3) 

to provide SMP education with targeted efforts to reach beneficiaries with homebound, 

disabled adults. The expected outcomes are: 1) an increase in information and tools to 

protect beneficiaries from fraud and scam seekers; 2) an increase in the number of SMPeducated 

seniors and disabled adults; and 3) an increase in health care cost savings. 

Products will include: brochures, pamphlets, and ads for the media. 




Project Title: Senior Medicare Patrol (SMP) Expansion 





1301 Gervais Street- Suite 350 


Contact: 

Gloria McDonald 

Tel. (803) 734-9902 

Email: mcdong@aging.sc.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $150,000 


The goal of the South Carolina Lieutenant Governor's Office on Aging is to expand the 

capability of the SMP program to recruit and train a cadre of volunteers to educate and 

empower Medicare and Medicaid beneficiaries and caregivers to recognize, detect and report 

health care fraud and abuse. The objectives are: 1) to provide fraud outreach in areas with 

the highest concentration of consumers and where incidences of misleading marketing 

practices and other frauds are prevalent; 2) to train local staff and volunteers; 3) to expand 

intervention using volunteers who are familiar with Medicare Summary Notices, billing 

practices and marketing policies; 4) to disseminate fraud information to an increased number 

of beneficiaries, including those who are homebound and hard to reach; 5) strengthen linkage 

with community agencies to increase reporting; and 6) to evaluate impact of additional 

volunteers on services/reporting. The expected outcomes are: 1) an increase in recruitment 

of volunteers; 2) an increase in the number of beneficiaries who know how to review the 

Medicare Summary Notice (MSN); 3) an increase number of beneficiaries who can detect 

and report other types of scams; and 4) an increase in the conduct of more multimedia 

events to promote the SMP program. The products to be developed include brochures, 

manuals, posters and media spots. 




Project Title: Tennessee Senior Medicare Patrol: Empowering Seniors to Prevent 

Healthcare Fraud 



Upper Cumberland Development District 

1225 S. Willow Avenue 

Cookville, TN 38509 

Contact: 

LaNelle Godsey 

Tel. (931) 432-4111 

Email: lgodsey@ucdd.org 


Fiscal 

Year 

Funding 

Amounts 









Total $126.969 


The goal of the Tennessee Senior Medicare Patrol (SMP) project is to strengthen the existing 

SMP project's efforts to empower Medicare and Medicaid beneficiaries and caregivers to 

prevent health care fraud, waste and abuse through outreach and education. The project will 

continue objectives pursued under its basic grant support. New objectives introduced 

include: 1) develop/update training modules on preventing fraud in specialized areas such as 

Medicaid and home health; 2) enhance the SMP website, conduct reviews of each contract 

AAAD to measure program performance; and 3) create a TN SMP Policy and Procedure 

manual to be a resource for all statewide staff. In addition to the objectives, Tennessee SMP 

will develop and print posters to disseminate to providers, order items for health fairs, and 

recognize our volunteers. 




Project Title: Expansion of the Texas Senior Medicare Patrol Project 


Fiscal 


Year 

Better Business Bureau Educational Foundation 

1333 West Loop South 

Houston, TX 77027-9116 

Contact: 

Candace Tywman 

Tel. No. (713) 341-6124 

Email: ctwyman@bbbhou.org 



Funding 

Amounts 









Total $430,000 

The Houston Better Business Bureau Education Foundations Senior Medicare Patrol (SMP) 

grant initially covered 10 counties in the Greater Houston area. The goals for this grant are: 

1) to expand the Texas SMP volunteer force; 2) to increase awareness of health care fraud 

through outreach and education; 3) to increase reports of Medicare fraud; and, 4) to build 

upon existing relationships with law enforcement and Center for Medicare and Medicaid 

Services contract investigators to expedite reporting of potential fraud. The objectives are: 

1) to establish partnerships focused on volunteer recruitment in both urban and rural 

communities; 2) to partner with the Health Care Fraud Prevention and Enforcement Action 

Team (HEAT) Strike Force to increase public awareness about health care fraud by 

implementing a media campaign utilizing materials developed by the Administration on Aging 

and the SMP National Resource Center; and 3) to increase the number of beneficiaries 

reached through outreach and education. The expected outcomes include: 1) expanded 

awareness of health care fraud and abuse across Texas; 2) increased number of volunteer 

work force; and 3) increased detection and reporting of fraud. Products will include a final 

report showing growth in capacity by increasing the number of volunteers, number of calls 

reporting Medicare fraud, and number of individuals reached through outreach and 

education. 




Project Title: Vermont Senior Medicare Patrol Expansion of Statewide 

Volunteerism and Outreach Project 



Community of Vermont Elders 

641 Comstock Rd., Suite 4 

P.O. Box 1276 

Berlin, VT 05602 

Contact: 

Anita Hoy 

Tel. (802) 229-4731 

Email: anita@vermontelders.org 


Fiscal 

Year 

Funding 

Amounts 









Total $50,000 


The Community of Vermont Elders (COVE) will expand the Vermont Senior Medicare Patrol 

(SMP) as a Medicare error, fraud and abuse education and prevention program, particularly 

through increased volunteerism and outreach. The goal is to expand the current pool of 

active volunteers to reach an increased number of Vermonters through a variety of new 

venues and exciting program activities, including an expansion of the COVE Savvy Senior 

programs. The objectives are: 1) to expand and enhance Vermont SMP's staff and volunteer 

workforce to provide education and outreach; 2) to expand collaborative activities with key 

stakeholders including the Vermont Senior Health Insurance Assistance Program, Lyric 

Theatre, and the Vermont Refugee Resettlement Project; 3) to expand SMP Outreach and 

Education to effectively reach a wider and more diverse population of Vermonters; 4) to 

monitor program reach and effectiveness through the use of national and statewide reporting 

and tracking tools, and; 5) to develop additional outreach materials and a toolkit that will be 

available for national dissemination. The expected outcomes are: 1) increased opportunity 

to educate a larger and more diverse audience; 2) improved and increased service delivery to 

beneficiaries; and 3) increased public support and new opportunities to promote SMP as a 

viable effective education and prevention program. Anticipated products included 

announcements, press materials, new and enhanced training toolkit and a skit. 




Project Title: Senior Medicare Patrol Expansion Capacity Building Project 



Virgin Islands Department of Human Services 

Division of Senior Citizen Affairs 

Knud Hansen Complex Building A 

Charlotte Amalie, VI 00802-9998 

Contact: 

Michael Rymer-Charles 

Tel. (340) 774-1166 

Email: mrhymercharles@dhs.gov.vi 


Fiscal 

Year 

Funding 

Amounts 









Total $20,000 


The goal of the Division of Senior Citizen Affairs in the Department of Human Services is to 

enhance existing services in the territory and to reach the St. Thomas district community to 

educate beneficiaries and their caregivers to become informed consumers while protecting 

the integrity of the Medicare and Medicaid programs. The objectives are: 1) to expand and 

enhance the project's volunteer workforce; 2) to expand outreach and education to 

beneficiaries specifically in the St. Thomas district; and 3) to expand the ability of the project 

to manage beneficiary inquiries and complaints in a timely, professional manner. The 

expected outcomes are: 1) increased recruitment and training of volunteers; 2) increased 

visibility; 3) expansion to hard-to-reach areas with specially trained volunteers; 4) increased 

outreach and resources for the limit English proficient population; and 5) increased number of 

volunteers receiving specialized training to handle inquiries and complaints. Products will 

include volunteer recruitment brochures in English and Spanish. 




Project Title: The Virginia Senior Medicare Patrol Project 



Virginia Association of Area Agencies on Aging 

24 East Cary Street, Suite 100 


Contact: 

Susan Johnson 

Tel. No. (804) 644-5628 

Email: sjohnson@thev4a.org 


Fiscal 

Year 

Funding 

Amounts 









Total $298,367 


The Virginia Association of Area Agencies on Aging’s Senior Medicare Patrol (SMP) will 

implement a one-year program expansion with Virginia’s local Area Agencies on Aging, the 

Virginia Department for the Aging, the Attorney General’s Medicaid Fraud Control Unit 

(MFCU) and TRIAD chapters, AARP, and the Virginia Bureau of Insurance. The program’s 

goal is to increase the number of educated consumers, caregivers and beneficiaries who are 

willing to report suspected Medicare, Medicaid, and health insurance fraud, error and abuse. 

The objectives include: 1) to hold 6-8 community forums with partners to provide education 

about health care reform; health care fraud, error and abuse; and prevention tools to 

beneficiaries and family members; 2) to increase the number of local volunteer and provider 

trainings in coordination with the AAA’s and the number of community outreach and 

education events; 3) to increase the number of confidential inquiries, reporting, and referrals 

about potential Medicare / Medicaid fraud made to the Virginia SMP toll-free hotline; 4) to 

promote Virginia’s SMP with a revised website; 5) to increase public awareness in urban and 

rural areas through print and radio advertisements; 6) to increase SMP’s capacity to 

coordinate volunteers and enhance responses to inquiries and complaints; and 7) to 

document the dissemination efforts to measure the effectiveness of the SMP strategies. The 

expected outcomes are: 1) an increase in local community-based outreach and education 

events; 2) an increase in confidential calls to the SMP 1-800 Hotline from educated Medicaid 

and Medicare program beneficiaries who suspect fraud, error, or abuse; and 3) an increased 

workload in the Attorney General’s Medicaid Fraud Unit and the federal Medicare fraud 

investigation units. Products will include brochures in English and other languages; training 

toolkit; refrigerator magnets; healthcare journal; and video clips. 




Project Title: Senior Medicare Project Capacity Building Grant 



Washington State Office of the Insurance Commissioner 

Consumer Protection 

PO Box 40256 

Olympia, WA 98504-0256 

Contact: 

Marijean Holland 

Tel. (360) 725-7091 

Email: MarijeanH@oic.wa.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $150,000 


The Statewide Health Insurance Benefits Advisors (SHIBA) HelpLine -- the Washington state 

Senior Medicare Patrol (SMP) Project -- supports this one-year SMP capacity building project 

in collaboration with key partners. They include various agencies that serve limited Englishspeaking 

and isolated Medicare and Medicaid beneficiaries across Washington State. The 

project goal is to expand the Washington State SMP project capacity to recruit, screen, train, 

manage and support an increased number of SMP volunteers to effectively expand SMP 

outreach to beneficiaries in local communities in a more comprehensive manner throughout 

the state. The project objectives include: 1) recruit, train, manage and support increased 

numbers of SMP volunteers, including those who are bilingual, to provide program coverage 

in additional communities; 2) expand SMP subcontracts with local community-based groups 

to help with Objective 1; 3) use innovative marketing strategies and social media to expand 

awareness of the SMP project to underserved communities statewide; 4) expand consumer 

outreach efforts to target limited English-speaking populations statewide through 

development of culturally competent materials; 5) allocate additional staff time to respond to 

beneficiary inquiries and complaints in a timely, professional manner, and effectively report 

cases to CMS contractors; 6) enhance SMP capacity for performance management, track 

and report results, and manage; and 7) train the increased cadre of volunteers. The 

expected outcome is increased awareness of SMP projects and its message to Medicare 

beneficiaries and their caregivers. Anticipated products are financial and progress reports; 

WA SMP blog or e-newsletter; public education and marketing materials, including some in 

other languages. 




Project Title: Senior Medicare Patrol Capacity Building in West Virginia 



AARP Foundation 



Contact: 

Julia Stephens 

Tel. (202) 434-2051 

Email: jstephens@aarp.org 



Fiscal 

Year 

Funding 

Amounts 









Total $88,750 

The West Virginia Senior Medicare Patrol (WVSMP) will recruit, screen, train, manage and 

support more volunteers and will expand outreach to beneficiaries in a comprehensive 

manner, ensuring statewide coverage. The goal is to expand the capacity of the WV SMP 

project to recruit, screen, train, manage, and support more SMP volunteers and to effectively 

expand SMP outreach to beneficiaries in a comprehensive manner. The objective is to 

educate as many beneficiaries as possible about how to detect, protect and report health 

care fraud, waste and abuse, through the work of the volunteers and through targeted, 

outreach activities. The WV SMP will complete this task by taking seven distinct steps: 1) 

hiring a volunteer coordinator, 2) conducting new volunteer recruitment activities, 3) hosting 

volunteer training workshops in locations geographically spread across the state, 4) 

partnering with the Area Agencies on Aging on referrals and outreach, 5) making targeted 

media buys and conducting outreach activities to three special populations - geographically 

isolated rural, Spanish-speaking and African-American beneficiaries, 6) conducting a "Ready, 

Set, Internet!" training workshop about how to stay safe from fraud while online, and 7) 

participating in the State’s 2nd Annual "Money Smart Week." Expected outcomes include: 1) 

measurable increases in the number of beneficiaries, their family members and caregivers 

receiving services offered by the WVSMP; 2) increased simple and complex inquiries and 

one-on-one counseling sessions; 3) increased awareness of the work of the WVSMP; 4) 

increased knowledge of WVSMP issues by our volunteers and by those served by the 

organization; and 5) additional volunteer outreach hours. Products include materials for print 

media buys. 




Project Title: Wisconsin Senior Medicare Patrol Coalition of Wisconsin Aging 

Groups Senior Medicare Patrol Project 



Coalition of Wisconsin Aging Groups 

Elder Law Center 

2850 Dairy Drive, Suite 100 

Madison, WI 53718-6742 

Contact: 

Bridget Erstad 

Tel. (608) 224-0607 

Email: bridgete@cwag.org 


Fiscal 

Year 

Funding 

Amounts 









Total $150,000 


The goal of this project is to expand Wisconsin Senior Medicare Patrol’s (SMP) capacity by 

increasing staff and by training selected volunteers to do more: as trainers themselves and as 

"first responders" to fraud complaints. Hiring a Grant Coordinator and Outreach Assistant will 

free the SMP Project Director and the SMP Volunteer Coordinator to concentrate on their 

respective position duties. The objectives are to: 1) enhance SMP’s ability to screen and 

train volunteers statewide in a timely manner; 2) provide advanced training to selected 

volunteers to enable them to train other new volunteers; 3) provide specialized training to 

selected volunteers to assist in researching and responding to complex issues; 4) expand 

education and outreach through Public Service Announcements (PSAs), podcasts, online 

and self-study courses; and 5) reach out to Wisconsin’s non-English speaking communities 

(especially Hmong and ideally Spanish) through specialized PSAs and presentations. The 

expected outcomes will be a more rapid response to complaints of possible fraud, quicker 

screening and training of potential volunteers, and expanded SMP presence in Wisconsin’s 

72 counties. This in turn will help us recruit dual-language volunteers. Additional staff will 

mean more time for SMART FACTS data entry, creation of educational materials, and 

locating and taking advantage of new outreach opportunities. The products will include a 

self-study course developed by SMP volunteers with backgrounds in health and education 

and an online course developed by the same group, both based on SMP Volunteer 

Foundations Training Curriculum; a variety of handouts, PSAs, flyers, and other material 

targeted to specific populations; an enhanced website; and a final report. 




Project Title: Senior Medicare Patrol- Capacity Building Grant 



Wyoming Senior Citizens, Inc. 

106 West Adams 

Riverton, WY 82501- 0000 

Contact: 

Charlie Simineo 

Tel. (307) 856-6880 

Email: execdir@wyoming.com 


Fiscal 

Year 

Funding 

Amounts 









Total $50,000 


The Wyoming Senior Citizens, Inc. Senior Medicare Patrol (SMP) program has a goal of 

increasing exposure to and education of 75,000 plus Medicare beneficiaries. The objective is 

to reach out to as many of Wyoming's senior citizens as possible in a reasonable amount of 

time given the size of the state and the small staff available to do so. The expected 

outcomes are: 1) hire an additional 0.5 FTE staff member to assist in recruiting more 

volunteers; and 2) an increased number of volunteers. The products will include a statewide 

mailing list and materials for the expansion of local radio SMP advertisements. 


Senior Medicare Patrol (SMP) Program – Statewide Expansion Grants 

The Administration on Aging (AoA) awards three year grants to States to support Senior 

Medicare Patrol (SMP) projects by staggering the years of new competitions. Since FY1996 

these basic support grants have focused on expanding the original localized programs to 

reach senior beneficiaries statewide. Continuation awards were made in FY2010 to States 

who received new grant awards in FY2008 and FY2009. 


Program: Senior Medicare Patrol (SMP) Program – Statewide Expansion Grants 


Project Title: Senior Medicare Patrol Program Grant 





770 Washington Ave., Suite 470 

Montgomery, AL 36130 

Contact: 

Robyn James 

Tel. (334) 353-9273 

Email: Robyn.James@ADSS.Alabama.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $360,000 


This is a three-year Senior Medicare Patrol (SMP) project grant to the Alabama Dept. of 

Senior Services (ADSS) to support an SMP program, in collaboration with the 13 Area 

Agencies on Aging. The goal of the project is to educate beneficiaries and providers to 

identify errors in Medicare billing to combat healthcare waste, fraud and abuse. The 

objectives are to: 1) educate beneficiaries and providers on how to identify errors in 

Medicare billing; 2) provide publications to educate beneficiaries on identifying potential fraud 

and abuse; 3) publicize a statewide 1-800 number for assistance; 4) establish an effective 

reporting mechanism to track outreach events, as well as potential fraud and abuse cases; 5) 

build partnerships with healthcare providers, Medicare carriers and fiscal intermediaries; and 

6) recruit & train volunteers. Expected outcomes are: 1) more rural, low-income, and non- 

English speaking aging consumers educated and aware of Medicare waste, fraud and abuse, 

2) measurable outcomes with post-evaluations at seminars will show a marked increase in 

the awareness and detection of fraud and abuse positively affecting target areas; 3) 

increased publicity on waste, fraud and abuse will be available statewide; 4) volunteers will 

be recruited and trained in rural and underserved areas; and 5) healthcare providers will 

begin to be trained to identify healthcare waste, fraud and abuse. Products will include a 

website with statewide resources; reference materials on waste, fraud and abuse; and 

community-based educational programs designed to provide tips on preventing and 

identifying waste, fraud and abuse, emphasizing the importance of protecting one's personal 

information; and required reports, including evaluation results. 




Project Title: Senior Medicare Patrol 




Senior and Disabilities Services 

550 West 8th Avenue 

Anchorage, AK 99501-3518 

Contact: 

Judith Bendersky 

Tel. (907) 269-3669 

Email: judith.bendersky@alaska.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $898,434 


This is a continuation of the Alaska Senior Medicare Patrol (SMP) Project to recruit and train 

local senior citizens in each group of communities, to educate Medicare beneficiaries and 

their families about the importance of recognizing and reporting Medicare and Medicaid 

fraud, error and abuse. The goal of the project is to implement a statewide plan that 

empowers senior volunteers to assist older persons to become educated about their health 

care expenditures under Medicare in order to prevent error, fraud, abuse and waste. The 

objective is to reach vulnerable, isolated and limited English speaking Medicare beneficiaries 

through partnership with the American Association of Retired Persons (AARP), Older 

Persons Action Group (OPAG), Alaska Native Tribal Health Consortium (ANTHC), and the 

Anchorage Senior Center and other local senior centers throughout the State of Alaska. 

Expected outcomes are: 1) increased number of volunteer counselors; 2) increased 

awareness regarding healthcare error, fraud, abuse and waste; 3) increased number of 

complaints by beneficiaries or partner agencies; and 4) increased savings attributable to the 

project. Products will include voice enhanced CD-ROMs; PowerPoint training materials; 

video teleconferences; brochures; and reports, as required. 




Project Title: Ferret Out Fraud - Senior Medicare Patrol Project 




Division of Aging and Adult Service 

1789 West Jefferson, 950A 

Phoenix, AZ 85007-3202 

Contact: 


Tel. No. (602) 542-5757 


AoA Project Officer: Dennis Dudley 

Fiscal 

Year 

Funding 

Amounts 









Total $1,019,829 


This is a continuation of the Arizona Department of Economic Security, Aging and Adult 

Administration’s Arizona Senior Medicare Patrol Project (ASMPP) to address the need to 

educate and disseminate information about Medicare/Medicaid error, fraud, and abuse in the 

health care system. The goals of the program are to build the capacity of the ASMPP to 

reach beneficiaries with special emphasis on expanding culturally sensitive and linguistically 

appropriate materials for beneficiaries and developing processes that will result in program 

improvement. The expected outcomes are: 1) beneficiaries, including those who are 

culturally diverse, will have increased awareness and knowledge in order to detect and 

prevent Medicare/Medicaid error, fraud and abuse; 2) Area Agency on Aging (AAA) staff and 

volunteers will have increased knowledge to educate beneficiaries, their families and other 

professionals on Medicare/Medicaid error, fraud and abuse; 3) AAA staff will have an 

increased understanding of tools to improve the ASMPP; and 4) Arizona Beneficiaries 

Coalition and Arizona Fraud Prevention Coalition members and other organizations will have 

increased opportunities to partner in efforts to educate and prevent Medicare/Medicaid error, 

fraud, and abuse. Products of this project include required reports, evaluation materials, and 

Spanish brochures. 







Arkansas Department of Health and Human Services 


P.O. Box 1437, Slot S530 


Contact: 

John Pollet 

Tel. (501) 682-8504 

Email: john.pollett@arkansas.gov 

AoA Project Officer: Lisa Theirl 

Fiscal 

Year 

Funding 

Amounts 









Total $1,078,590 


This is a continuation of the Arkansas Division of Aging and Adult Services to administer the 

Senior Medicare Patrol (SMP) project in collaboration with regional partners committed to 

consumer education and the protection of the aging and disabled populations of the state. 

The goal of the project is to empower senior beneficiaries to identify, prevent, and report 

healthcare fraud, waste and abuse. The target populations are the vulnerable and 

underserved, such as those impacted by low literacy, low income, cultural barriers and 

geographic isolation. The objectives are to: 1) train partners and volunteers to present the 

Arkansas SMP (ASMP) message; 2) educate and empower seniors to prevent healthcare 

fraud; 3) collaborate with the aging, minority and disability communities to reach underserved 

populations regarding healthcare fraud and health literacy; 4) package the ASMP healthcare 

fraud and abuse message and health literacy message together with information the public 

wants and needs; and 5) share all educational materials developed with seniors across the 

state and with other SMPs. The expected outcomes are: 1) increased beneficiary awareness 

of healthcare fraud and abuse, as indicated in surveys returned after group sessions; 2) 

increased effectiveness of activities to reach minority, rural, low-literate and non-English 

speaking populations; and 3) increased effectiveness of ASMP volunteers to educate 

beneficiaries in the areas of Medicare Basics (Parts A, B, C, & D), healthcare fraud, waste, 

and abuse; volunteer reporting; low-income subsidies; and Medicare Rights. Products will 

include brochures, training modules, "tip sheets", and reports as required. 




Project Title: California Senior Medicare Patrol (SMP) 



California Health Advocates (CHA) 

5380 Elvas Avenue Suite 124 


Contact: 

Julie Schoen 

Tel. No. (714) 560-0309 

Email: jschoen@cahealthadvocates.org 

AoA Project Officer: Sau Wo D. Lam 

Fiscal 

Year 

Funding 

Amounts 









Total $180,000 


This is a continuation of a three-year grant to the California Health Advocates (CHA). The 

CHA Senior Medicare Patrol (SMP) has statewide coverage and a national presence. The 

objects are to: 1) collaborate with already established creditable organizations; 2) utilize a 

statewide 800 number in partnership with the State Health Information Program (SHIP); 3) 

refine relationships with other agencies to improve case tracking, communication and 

recoupment outcomes; 4) participate in state/regional organizations; 5) partner with California 

Medicare Coalition, Latino Health Access, Asian Pacific Islander Coalition, Office on Aging 

groups; 6) provide necessary reporting forms and training materials via Internet; 7) identify 

high profile cases that will substantiate credibility and value of the SMPs nationwide; 8) 

maintain and improve our cohesive case tracking system; 9) improve the efficiency of the 

SMP program, while increasing results for both operational and quality measures; 10) reach 

underserved populations by hiring staff with bi-lingual capabilities and proven track records in 

outreach and service; 11) and be recognized collectively as a national program with the other 

Administration on Aging (AoA) SMPs and the National Technical Resource Center. Expected 

measurable outcomes are: 1) provision of a minimum of 12 training sessions per year; 2) a 

volunteer base of 800 statewide; 3) provision of a yearly conferences on fraud and abuse 

issues for managers; 4) report of a minimum of 24 cases of fraud annually; 5) an increase 

savings to Medicare from $1.5 million to $3.0 million; 6) an increase numbers of elderly 

educated from current average of 10,000 to 12,000 per year; and 7) target training and 

education to isolated and hard-to-reach populations. Products will include a newsletter; fact 

sheets; placemats; website; brochures; flyer for hard-to-reach populations; and a final report. 




Project Title: Anti-Fraud Education Project 



Colorado Department of Regulatory Agencies 

Division of Insurance 

1560 Broadway, Suite 850 


Contact: 

Suzanne R. Sigona 

Tel. (303) 894-7541 

Email: suzanne.sigona@dora.state.co.us 


Fiscal 

Year 

Funding 

Amounts 









Total $1,042,773 


This is a continuation of the Colorado Division of Insurance project, through its Senior Health 

Insurance Assistance Program (SHIP), to support the Senior Medicare Patrol (SMP) project, 

in collaboration with 16 SHIP affiliates and Colorado Access to Benefits Coalition (ABC) 

members. The goals are to: promote an understanding of Medicare/Medicaid fraud and 

abuse among consumers/caregivers; increase reporting when fraud and abuse occurs; and 

decrease the incidence of Medicare and Medicaid fraud and abuse in Colorado. The 

objectives are to: 1) provide consumer education on anti-fraud messages; assist consumers 

with fraud/abuse complaints; and 2) continue development of network of organizations and 

individuals delivering the message and assisting those who suspect fraud and/or abuse, with 

an emphasis on reaching out to rural and minority populations. The expected outcomes are: 

1) increased placement of effective messages in applicable consumer publications; 2) 

expanded network (individuals, agencies, media) for dissemination of anti-fraud messages;3) 

increased awareness of potential Medicare fraud among Colorado consumers; 4) a decrease 

in the incidence of undetected cases of Medicare fraud/abuse in the State; and 5) an 

increase in the resolution of reported cases of suspected fraud and/or abuse. The products 

from this project are SMP brochures, Personal Healthcare Journals, fraud alerts, consumer 

presentations, fraud messages in partner consumer-oriented materials, semi-annual narrative 

reports with evaluation data and financial reports, as required. 




Project Title: Connecticut CHOICES Senior Medicare Patrol Project 







Contact: 

Dee White 

Tel. (860) 425-5008 

Email: dee.white@ct.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $360,000 


This is a continuation of a three-year grant awarded to the Connecticut Department of Social 

Services. The goal is to enable beneficiaries to become better health care consumers by 

increasing their awareness of Medicare, Medicaid, and other potential incidents of health care 

fraud, errors, abuse and scams in order to detect and reduce improper payments and prevent 

victimization of themselves and others by ferreting out fraudulent scams and practices. The 

objectives are to: 1) enhance/create partnerships utilizing volunteers; 2) improve program 

visibility through an awareness campaign; 3) provide education to beneficiaries and 

professionals, specifically targeting homebound and other isolated and/or hard to reach 

populations; and 4) improve project efficiency, while increasing both operational and quality 

measures. Targeted areas include seniors in urban and rural areas with a high concentration 

of underserved seniors, but which have produced a disproportionately low number of clients: 

African American and Hispanic seniors; and isolated homebound seniors. Expected 

outcomes include: 1) increased awareness among consumers of health care fraud, abuse 

and related scams; 2) increased accessibility, quantity and effectiveness of information 

available to help targeted populations from being victimized; 3) increased awareness of fraud 

and abuse issues of those professionals involved with homebound/homecare clients; 4) 

expanded programming for and participation of volunteers in community initiatives; and 5) 

increased beneficiary inquiries and reports of suspected fraud, waste or abuse that result in 

action and savings attributable to the project. Products from the project include a web-based 

training program, power point presentations, and outreach materials. 




Project Title: Delaware Medicare Patrol Project 



Delaware Department of Health and Human Services 

1901 N. DuPont Highway, Main Annex 


Contact: 

Cynthia Allen 

Tel. (302) 255-9390 

Email: cynthia.allen@state.de.us 


Fiscal 

Year 

Funding 

Amounts 









Total $993,583 


This is a continuation of the Division of Services for Aging and Adults with Physical 

Disabilities (DSAAPD) support of the Senior Medicare Patrol (SMP) project, in collaboration 

with State of Delaware Department of Health and Social Services, ElderInfo (SHIP), Medicaid 

Fraud, and related fraud or Medicare groups. The goal of the project is continue to reach 

vulnerable and hard to reach Medicare and Medicaid beneficiaries through trained volunteers 

by providing education, developing reading materials at a low reading level and maintaining 

federal, state, and local partnerships. The objectives are to: 1) continue to recruit and train 

culturally aware, bilingual, retired professionals with experience in health care, 

communication and education to teach Medicare and Medicaid beneficiaries and their 

families throughout Delaware; 2) continue or to develop partnerships with Federal, State and 

local agencies with new and creative strategies for reaching out to the culturally diverse, low 

income, low literate, and isolated Medicare and Medicaid beneficiaries; and 3) develop and 

implement a marketing outreach plan, using research conducted to effectively reach and 

educate vulnerable and hard to reach diverse seniors. The expected outcome is an 

increased number of contacts to the 800 number, by email, or other communication, due to 

our outreach efforts. The products from this project are a Smart Facts generated OIG report 

with data assessment reports; a website; press releases and articles for publications; 

newsletters and flyers; and in-house training, and reports as required. 








601 E Street, NW, Building A, A4 


Contact: 

Jan May 

Tel. (202) 434-2164 

Email: jmay@aarp.org 

AoA Project Officer: Barry F. Klisberg 

Fiscal 

Year 

Funding 

Amounts 









Total $1.20,000 


This is a continuation of the Senior Medicare Error Patrol Project (SMEPP), a cooperative 

agreement project administered by the Legal Counsel for the Elderly, Inc. (LCE). Per the 

new program specifications of the Administration on Aging (AoA), LCE will expand the Senior 

Medicare Patrol (SMP) District-wide. The goal of the SMEPP is to teach District of Columbia 

Medicare and Medicaid beneficiaries how to detect and prevent healthcare fraud and waste. 

The objectives are to: 1) reach out to all 8 wards in the District of Columbia, particularly hard 

to reach segments of African American, Hispanic, and Asian Pacific American populations 

and institutions; 2) collaborate with the District of Columbia Office on Aging and its Senior 

Service Network to realize healthcare system savings; 3) recruit and train diverse volunteers 

to enhance culturally-effective outreach; 4) improve data collection via a SMARTFACTS 

database and through updates and trainings from the National Consumer Protection 

Resource Center; and 5) increase SMP visibility through radio, television, print and online 

media, highlighting its successes. Expected outcomes are: 1) increased awareness of 

healthcare fraud and abuse within hard-to-reach populations throughout the District; 2) 

increased participation in multilingual and multicultural educational seminars; 3) increased 

promotion of the SMP Hotline to ensure complaints were referred to proper authorities in a 

timely manner; increased dissemination of SMP materials through radio, television, print, and 

online media outlets; 4) increased project effectiveness via SMARTFACTS; and 5) increased 

documentation cost savings to the Medicare and Medicaid programs and beneficiaries. 

Products include brochures, pamphlets, and a final report. 




Project Title: National Hispanic Senior Medicare Patrol (SMP) Project 



National Hispanic Council on Aging 

734 15th Street NW Suite 1050 


Contact: 

Maria E. Hernandez-Lane 

Tel. (202) 347-9735 

Email: mlane@nhcoa.org 


Fiscal 

Year 

Funding 

Amounts 









Total $630,000 


The National Hispanic Council on Aging (NHCOA) supports this three-year project focusing 

on outreach and education in areas with high Hispanic populations. The goal for the project 

is to educate Hispanic older adults of Mexican, Cuban, Central American, South American, 

Caribbean, and other Latino origins about Medicare, Medicaid and home healthcare fraud 

and abuse prevention and reporting, by crafting comprehensive programs tailored to the 

specific characteristics and needs of all the different Hispanic groups in the country. 

The objectives are to: 1) concentrate on outreach and education in areas with high Hispanic 

populations; 2) expand the education focus to include Medicaid and home health care; 3) lay 

groundwork for a nationwide social marketing campaign to promote behaviors that lead to the 

prevention and reporting of Medicare fraud; and 4) develop a web-based cultural competency 

course targeting healthcare providers and pharmacies. Expected outcomes: 1) increased 

understanding of the Medicare, Medicaid and home healthcare systems, fraud and abuse 

and ways to report fraud; 2) increased avenues for reporting fraud and abuse among 

beneficiaries and their families; and 3) increased awareness of culturally-competent practices 

in relation to Medicare for Hispanic older adults. Products will include educational materials 

specific to each Hispanic population. 




Project Title: Senior Medicare and Medicaid Patrol of Florida 



Area Agency on Aging of Pasco-Pinellas, Inc. 

9887 4th Street North, Suite 100 

St Petersburg, FL 33702 

Contact: 

Sally Gronda 

Tel. No. (727) 570-9696 

Email: grondas@elderaffairs.org 


Fiscal 

Year 

Funding 

Amounts 









Total $1,040,000 


This is a continuation of the Area Agency on Aging of Pasco-Pinellas, Inc. (AAAPP) Senior 

Medicare Patrol (SMP) program. The goal is to build upon past experiences and expand 

outreach statewide through strategic partnerships representing a variety of programs whose 

missions coincide with the SMP. The objectives are to: 1) expand the Steering Committee 

statewide; 2) establish new partnerships/collaborations to assist in expanding the program 

statewide and reaching underserved populations; 3) develop and implement a marketing and 

outreach plan that is culturally competent; 4) develop and implement innovative strategies to 

expand outreach and education statewide; 5) expand volunteer recruitment efforts in the 

current project areas of Pasco and Pinellas counties; 6) expand volunteer training to 

incorporate the new Medicare Modernization Act; 7) and expand volunteer recognition efforts 

statewide. Expected outcomes include: 1) an increase in the number of complaints to the 

statewide SMP fraud hotline as a result of an expanded marketing and outreach campaign; 2) 

an increase in the involvement of retired professionals, particularly older minority individuals, 

in Medicare/Medicaid education and training; and 3) increased awareness/knowledge among 

seniors about fraudulent practices and Medicare Part D. Products will include a web page; 

brochures and posters; data/results of community education; articles and interviews for 

publication; and a final report, including evaluation results. 




Project Title: Senior Medicare Patrol (SMP) 



Georgia Department of Human Resources 


2 Peachtree Street, NW 


Contact: 

Belinda J. Jones 

Tel. No. (404) 657-8756 

Email: bjjones@dhr.state.ga.us 


Fiscal 

Year 

Funding 

Amounts 









Total $1,040,000 


This is a continuation of the Georgia Department of Human Resources (DHR), GeorgiaCares 

Senior Medicare Patrol (SMP) project. The goal of this project is to empower Georgians to 

become better informed healthcare consumers, who are able to recognize quality healthcare, 

fraud, error, abuse and waste. The project objectives are to increase: 1) awareness of fraud 

and the SMP among Georgia's citizens; 2) capacity of outreach through the expansion and 

development of partnerships; 3) the number of active recruited volunteers; 4) opportunities to 

provide new training methods to local, certified coordinators for program and volunteer 

management; and 5) capacity to reach target populations. Expected outcomes: 1) 100% of 

all persons completing beneficiary surveys and training evaluations after attending SMP 

trainings and/or community education sessions will demonstrate an increase in awareness of 

Medicare and Medicaid error, fraud and abuse; 2) increased number of active, recruited 

volunteers entered into the Aging Information Management System (AIMS); 3) increased 

program outcomes entered into SmartFacts, AoA's web-based data management system; 4) 

increased outreach activities; and 5) increased capacity to reach target populations. 

Products will consist of: completion of the upgrade to the Aging Information Management 

System (AIMS) database to better capture and utilize client date; a final report, including 

evaluation results, client demographics, program monitoring, successes and areas needing 

improvement; shared website utilization with GeorgiaCares SHIP program to promote 

utilization of socially isolated populations to obtain needed and relevant information on 

Medicare/Medicaid fraud, error, abuse and waste reporting and resources. 




Project Title: 2009 Guam Senior Medicare Patrol Project (SMP) 



Guam Department of Public Health and Social Services 

Division of Senior Citizens 

123 Chalan Kareta 

Mangilao, GU 96913- 6304 

Contact: 

J. Peter Roberto 

Tel. (671) 736-7102 

Email: caring.communities@yahoo.com 


Fiscal 

Year 

Funding 

Amounts 









Total $150,000 


This is a continuation of a three-year Senior Medicare Patrol (SMP) project. The goal of the 

Guam SMP Project is to continue expanding and further enhancing the project for the 

purpose of educating Medicare and Medicaid beneficiaries, family members, and caregivers 

to actively protect themselves against fraudulent, wasteful and abusive health care practices 

and to report suspected errors. Guam SMP project objectives are to: 1) train members of 

the American Association of Retired Persons, local chapter, to serve as Guam SMP project 

volunteer resources and educators; 2) educate and provide community awareness of 

Medicare/Medicaid waste, fraud and abuse; 3) disseminate, in various formats, project 

information on Medicare/Medicaid waste, fraud and abuse; 4) foster current and establish 

new partnerships; and 5) evaluate project activities and communicate project outcomes. 

Expected measurable outcomes are: 1) an increased number of proficiently trained 

volunteers; 2) increased numbers of education beneficiaries, families and caregivers; 3) 

increased tracking of inquiries and the rate of inquiry resolution; and 4) increased 

Medicare/Medicaid savings. Products will include consumer driven, culturally appropriate 

informational materials; volunteer training items, e.g. training manual, volunteer incentives 

and certificates of appreciation; evaluation tools, and required reports. 







Hawaii Executive Office on Aging 

250 South Hotel Street 


Contact: 


Tel. (808) 586-0100 


AoA Project Officer: Anna H. Cirko-Godycki 

Fiscal 

Year 

Funding 

Amounts 









Total $360,000 


This is a three-year grant to continue a Senior Medicare Patrol (SMP) in the State of Hawaii's 

Executive Office on Aging. SMP Hawaii works closely with partners in the aging network, law 

enforcement, and various community advocacy organizations. The goal of the project is to 

encourage seniors to become self-advocates, protecting themselves, their families and their 

communities from financial, consumer and healthcare fraud. Program objectives are to: 1) 

establish working partnerships and multi-agency projects with local, state, and federal law 

enforcement agencies; 2) reach out to isolated, underserved, and non-English populations, 

i.e., Native Hawaiians, Southeast Asian, homebound; 3) develop and replicate innovative 

outreach tools; and develop 4) volunteer recruitment, retention, and training strategies. 

Expected project outcomes: 1) four advisory council meetings with representatives from law 

enforcement, regulatory, consumer advocacy, and aging network organizations; 2) fraud 

prevention and resource fairs on Oahu and neighbor islands (Oahu, Hawaii, Maui, and 

Kauai); 3) development and replication of a DVD to highlight various healthcare fraud 

schemes, i.e., durable medical equipment, home healthcare, HMO, Part D; 4) recruitment 

and training of10 volunteers in both Native Hawaiian and Southeast Asian communities; and 

5) development and distribution of a fraud prevention and awareness booklet. Products will 

include a DVD; potholders with program information; brochures; fraud awareness and 

prevention booklet; and project reports, including evaluation results. 




Project Title: Idaho Medicare Education Partnership 




341 W Washington St 

PO Box 83720 


Contact: 

Donna Denny 

Tel. (208) 577-2854 

Email: donna.denney@aging.idaho.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $1,080,000 


This is a continuation of a cooperative agreement awarded to the Idaho Commission on 

Aging (ICOA). The Idaho Senior Medicare Patrol Project works with Senior Health Insurance 

Benefit Advisors (SHIBA), the Pocatello Area Agency on Aging, and the Hispanic Outreach 

Division of Canyon County Office on Aging, to use trained volunteers to educate beneficiaries 

in understanding and analyzing their Medicare billing information. The goal is further 

penetration into the senior community to expand consumer awareness of fraud by utilizing 

trained volunteers to educate and empower beneficiaries to scrutinize their Medicare billing 

information and flag unusual entries or charges, and to forewarn seniors on identity theft, 

consumer fraud and other health care scams. The objectives are to: 1) foster a statewide 

education program for Idaho beneficiaries and their caregivers in analysis of the Medicare 

Billing Summary Notices; 2) carry forward this prevention approach in the context of other 

types of health care fraud, by partnering with other entities, such as the Idaho Health Care 

Association and Idaho private insurance carries; 3) extend the programs' visibility through the 

Aging and Disability Resource Center in Northern Idaho; 4) improve efficiency by training 

staff and volunteers to fully utilize the SMARTFACTS SYSTEM; and forge relationships with 

harder to reach populations, such as Idaho's Native Americans and Hispanics. Expected 

outcomes are: 1) increased frequency of reports by seniors in detecting instances of 

suspected fraud; and 2) reduced numbers of seniors falling prey to scams and fraudulent 

business practices. Products will include a final report, including evaluation results; updates 

on the ICOA website; articles in the ICOA Newsletter and press releases; and regular 

program information disseminated through presentations at Senior Centers and during town 

hall events hosted by the Governor. 




Project Title: Statewide Illinois Senior Medicare Patrol (SMP) Program 



AgeOptions 

1048 Lake St., Suite 300 

Oak Park, IL 60301 

Contact: 

Anne Posner 

Tel. (708) 383-0258 

Email: anne.posner@ageoptions.org 

AoA Project Officer: Amelia Wiatr 

Fiscal 

Year 

Funding 

Amounts 









Total $360,000 


This is a three-year continuation grant to the Suburban Area Agency on Aging-AgeOptions, 

for the Senior Medicare Patrol (SMP) program for the state of Illinois. The goal of the 

program is to recruit and train volunteers to conduct health care fraud control, outreach and 

education. The objectives are to: 1) foster national and statewide program coverage; 2) 

improve beneficiary education and inquiry resolution for other areas of health care fraud; 3) 

foster national program visibility and consistency; 4) improve the efficiency of the SMP 

program, while increasing results for both operational and quality measures; and 5) target 

training and education to isolated and hard-to-reach populations. The expected outcomes 

are: 1) statewide coverage through collaborations with all the Area Agencies in Illinois; 2) a 

centralized intake system to report health care fraud; 3) a statewide media campaign; 4) 

expansion of the SMP message to people with disabilities through partnership with the Illinois 

Network for Centers for Independent Living (INCIL); 5) improved targeting to ethnic and 

limited English speaking seniors through partnership with the Coalition for Limited English 

Speaking Elderly (CLESE); 6) increased awareness about Medicare Part D and Durable 

Medical Equipment (DME) fraud; 7) consistent branding of the program with the national SMP 

effort; 8) an increased number of people reached with the SMP message; and 9) suggested 

best practices for reaching and educating isolated and hard-to-reach populations. The 

products from this project will be project reports, as required, including evaluation results; a 

website; newsletters; SMP power point presentation; SMP posters; playing cards; a fraud 

prevention toolkit; and an SMP brochure. 







Indiana Association of Area Agencies on Aging 

Education Institute 

4755 Kingsway Drive, Suite 402, Suite 402 


Contact: 

Kristen S. LaEace 

Tel. (317) 205-9201 

Email: klaeace@iaaaa.org 

AoA Project Officer: Amelia R. Watr 

Fiscal 

Year 

Funding 

Amounts 









Total $360,000 


This is the first year of a three-year continuation grant to the Indiana Association of Area 

Agencies on Aging (IAAAA) Education Institute, Inc. to continue an education and training 

model, the Indiana Senior Medicare Patrol (SMP) project. The goal is to create an education 

and training model on Medicare fraud prevention, including Part D, for elder volunteers and 

others who work with underserved Medicare populations including rural, low income and 

African American groups. The objectives are to: 1) continue working with established 

partners to foster national and statewide program coverage; 2) improve beneficiary education 

and inquiry resolution for other areas of health care fraud; 3) foster national program visibility 

and consistency; 4) improve the efficiency of the SMP program, while increasing results for 

both operational and quality measures; and 5) target training and education to isolated and 

hard-to-reach populations. The expected outcomes are: 1) an increase in the beneficiary 

knowledge of Medicare fraud and abuse; and 2) a 10% increase in the number of complaints 

reported/received over the life of the project. Products will include brochures, personal health 

care journals, Medicare Summary Notice (MSN) guides and informational sheets, project 

reports as required, including evaluation results. 




Project Title: Iowa Senior Medicare Patrol (SMP) 



Hawkeye Valley Area Agency on Aging, Inc. 

2101 Kimball Ave, Suite 320 

P O Box 388 


Contact: 

Shirley Merner 

Tel. (319) 272-2244 

Email: smerner@hvaaa.org 

AoA Project Officer: Amelia R. Watr 

Fiscal 

Year 

Funding 

Amounts 









Total $360,000 


The Hawkeye Valley Area Agency on Aging (HVAAA) is in its first year of a three-year Senior 

Medicare Patrol Project (SMP) grant application. The SMP's major partners include Iowa's 

Area Agencies on Aging (AAA), and Iowa EXPORT Center of Excellence on Health 

Disparities (Project EXPORT) located at the University of Northern Iowa. Through these 

partnerships, the SMP continues to achieve statewide coverage, expert knowledge of 

underserved populations, expertise in design of culturally-sensitive marketing and 

educational materials, and previously established community relationships. The project's goal 

is to recruit, train, and empower retired professionals to create responsible beneficiaries of 

healthcare statewide. The focus of this project is to increase outreach and education to 

include Iowa's isolated and hard-to-reach, underserved populations including African 

American, Asian, Hispanic, Native American, rural Iowans and other emerging populations. 

The objectives: 1) improve program efficiency statewide; 3) foster and nurture statewide 

coverage and increase outreach to target populations; 4) increase public awareness to 

underserved populations; 5) improve beneficiary healthcare education by focusing on 

underserved populations; and 6) foster national SMP visibility and recognition for Iowa SMP's 

outreach project. The expected outcomes are: 1) targeted elderly population will be 

equipped to be good stewards of healthcare dollars; 2) recovery of misspent healthcare 

dollars will increase; and 3) an increase in the number of reports of healthcare concerns for 

resolution or investigation. The products from this continuation project include folders; 

informational handouts that are culturally sensitive; an updated ID theft brochure; give-away 

items for use at health fairs and presentations; and reports as required, including evaluation 

results. Project lessons learned will be provided to the AoA National Consumer Protection 

Technical Resource Center (NCPTRC). 








503 S Kansas Ave 


Contact: 

Tina Langley 

Tel. (785) 296-5222 


AoA Project Officer: Amelia R. Wiatr 

Fiscal 

Year 

Funding 

Amounts 









Total $426,513 


This is a continuation grant for the Kansas Department on Aging. The goal of the Kansas 

Senior Medicare Patrol Project (SMP) is to increase understanding of fraud issues and 

increase the detection and reporting of errors, fraud, and abuse by beneficiaries. The 

objectives are to: 1) foster statewide program coverage through partnerships with volunteer 

networks and use of a toll-free number and interactive website; 2) improve beneficiary 

education and inquiry resolution for health care fraud in the Medicaid system; 3) foster 

national program visibility by working with the State Health Insurance Information Program 

(SHIP) and Aging and Disability Resource Centers (ADRC) programs and by utilizing a webbased 

data collection system; 4) improve the efficiency of data tracking and demonstrate an 

increase in program measures by utilizing SMARTFACTS; and 5) target education to lowincome 

populations, residents in nursing facilities, and Spanish-speaking beneficiaries. 

Expected outcomes are: 1) an increase in the number of counties having trained SMP 

volunteers; 2) an increase in the number of volunteers conducting education activities; 3) an 

increase in the number of beneficiaries receiving education; an increase in the number of 

"simple inquiries" received; and 4) an increase in the number of "complex issues" received. 

The products will include Office of the Inspector General (OIG) reports generated through 

SMARTFACTS; program materials developed for our target populations; narrative reports 

detailing strategies and results; and other reports, as required. 




Project Title: Senior Medicare Patrol (SMP) Kentucky 



Louisville/Jefferson County Metro Government 

Attn: Public Health and Wellness 

527 West Jefferson Street 

Louisville, KY 40202 

Contact: 

Betty Adkins 

Tel. No. (502) 574-2003 

Email: betty.adkins@louivilleky.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $782,610 


This is a continuation of a grant to the Louisville Metro Government Community Action 

Partnership (LMCAP) to operate the statewide Senior Medicare Patrol program, the Kentucky 

Senior Medicare Patrol (KYSMP), through seven regional existing Retired Senior Volunteer 

Programs (RSVPs). The goal is to maintain a pool of volunteers (a target of 335 people age 

55 and older) to act as Medicare educators throughout the state. The objectives are to: 1) 

broaden educational services to Medicare and Medicaid beneficiaries in all 120 Kentucky 

counties; 2) recruit and train 50 new senior volunteers; 3) integrate KYSMP services into 10 

statewide Community Action Partnerships (CAPs) and 2 Legal Aid Offices in the eastern and 

northeastern counties of the state; 4) update training manual inserts; 5) identify new 

statewide partnerships for collaboration on community outreach events that focus on 

educating the general retiring public; and 6) research and develop strategies to reach English 

as a Second Language populations. Expected outcomes are: 1) an increase in the number 

of educational services to beneficiaries; 2) more established partnerships to preserve integrity 

of Medicare/Medicaid programs; and 3) an increase in the number of knowledgeable 

beneficiaries of healthcare fraud in the Medicare and Medicaid programs. Products will 

include project reports, including evaluation results, as required; educational materials for 

volunteers and beneficiaries; group session post survey results; personal healthcare journals; 

and data tracking reports. 



Grant Number: 90MPMP0018 

Project Title: Louisiana Senior Medicare Patrol Project 



Louisiana Health Care Review, Inc. 

8591 United Plaza Blvd., Suite 270 


Contact: 

Tricia C. Canella 

Tel. (225) 248-7064 

Email: tcanella@lhcr.org 


Fiscal 

Year 

Funding 

Amounts 









Total $360,000 


This is a continuation of a three-year grant to the Louisiana Health Care Review, Inc. (LHCR) 

which is the Medicare Quality Improvement Organization (QIO) for Medicare in Louisiana 

under contract with the Centers for Medicare and Medicaid Services. Working in partnership 

with the LHCR, Office of Elderly Affairs (OEA), Senior Health Insurance Information Program 

(SHIIP) and other aging related organizations such as the Louisiana Medicaid Fraud Control 

Unit and the USDA Rural Assistance Program and will be supported by LHCR. The goal is to 

create a network of volunteers recruited from the Louisiana Retired Teachers' Association 

that work through the state's Aging and Disability Resource Centers (ADRC) and the Area 

Agencies on Aging (AAA) to train beneficiaries to detect, report, and prevent healthcare 

fraud. The Louisiana Senior Medicare Patrol (LASMP) will be a statewide effort, with an 

additional focus on the elderly homebound living in rural and hard-to-reach areas of the state, 

mainly in Medically Underserved and Healthcare Professional Shortage areas. The 

objectives are to: 1) recruit and support volunteers statewide; 2) increase fraud education 

among Medicaid beneficiaries; 3) implement a web-based seamless data collection system; 

4) improve the efficiency of LaSMP by increasing both operational and quality measures; and 

5) achieve sustainability for future efforts by coordinating all of the state's agencies that 

investigate fraud and elderly abuse. Expected outcomes: 1) improved dialogue between 

patients and their health care provider; 2) reduced number of coding errors; 3) improved 

health outcomes by insuring that services ordered by the physician are delivered; 4) 

development of an interactive fraud prevention web site; and 5) creation of a unified state 

agency fraud initiative. Products will include a survey, fraud prevention website, and reports 

as required. 









32 Blossom Lane, SHS 11 

August, ME 04333-0011 

Contact: 

Kathy Poulin 

Tel. No. (207) 287-9206 


AoA Project Officer: Christine Ramirez 

Fiscal 

Year 

Funding 

Amounts 









Total $1,080,000 


This is a continuation of the Maine Senior Medicare Patrol (SMP) Project, Maine Department 

of Health and Human Services. The goal is to educate beneficiaries, MaineCare (Medicaid) 

participants, their families and caregivers about Medicare benefits and empower them to 

identify and report health care errors, fraud and abuse. The objectives are to: 1) train 

SHIP/SMP volunteers and staff; 2) provide statewide outreach and education through 

expanded collaboration with the Maine SHIP and statewide, regional and community 

organizations; and 3) increase the number of health care fraud complaints referred to 

Medicare and MaineCare. The expected outcome is an increased number of educated 

Medicare beneficiaries, MaineCare participants, their families, and caregivers who are 

knowledgeable, responsible consumers who will detect and report health care fraud. 

Products will include flyers, presentations, brochures, information cards, health journals, 

posters, a Community Medicare Advocate's Handbook, a new on-line SHI/SMP training tool, 

training materials, and Medicare Bingo. A final report and presentations will be developed to 

share information with the AoA, the Centers for Medicare and Medicaid Services (CMS), the 

National Consumer Technical Resource Center, other SMPs and SHIPs. 




Project Title: Maryland SMP- Senior Medicare Patrol Project 




Client and Community Services 

301 W. Preston Street- Suite 1007 


Contact: 

Wiley Finch 

Tel. (401) 767-1278 

Email: acb@ooa.state.md.us 


Fiscal 

Year 

Funding 

Amounts 









Total $360,000 


This is a three-year continuation of the Senior Medicare Patrol (SMP) project operated by he 

Maryland Department of Aging (MDoA). The goals are to: 1) increase senior awareness of 

health care fraud, waste, abuse and error; 2) to mobilize state and community resources to 

work together in resolving and publicizing health care fraud concerns; and 3) to support the 

goals of the AoA Senior Medicare Patrol. The objectives are to: 1) develop partnerships and 

collaborations to ensure statewide program coverage; 2) improve beneficiary education and 

inquiry resolution for other areas of health care fraud; 3) increase awareness for beneficiaries 

about the problem of healthcare, fraud waste and abuse; 4) identify and test best practices to 

reach the hard-to-reach population; 5) target training and education to isolated and hard-toreach 

populations; 6) recruit and train volunteers with a variety of skills and education; 7) 

foster program visibility and consistency; 8) incorporate the new SMP logo and tagline in all 

MDoA and AAA SMP materials; and 9) incorporate the use of the Smartfacts reporting 

system in Maryland's Senior Medicare Patrol Program. Expected outcomes are to: 1) 

provide statewide outreach to Medicare and Medicaid beneficiaries and their families; 2) 

receive inquiries of suspected incidences of fraud, waste, error or abuse; 3) document 

estimated savings attributable to the project; 4) develop new partnerships; 5) assist 

individuals; and 7) recruit, educate and train a volunteer corps of retired professionals. The 

products from the project will include an assessment survey for Medicare beneficiaries; a 

paper on building partnerships with non-English communities; an updated training curriculum; 

a new SMP brochure; and an enhanced web site. 




Project Title: Massachusetts Medicare and Medicaid Outreach and Education 

Program "Senior Medicare Patrol Project" 



Elder Services of the Merrimack Valley, Inc. 

360 Merrimack Street, Building #5 

Lawrence, MA 01843 

Contact: 

Dayna Brown 

Tel. No. (978) 946-1368 

Email: Dbrown@esmv.org 


Fiscal 

Year 

Funding 

Amounts 









Total $1,040,000 


This is a continuation of the Elder Services of the Merrimack Valley, Inc. grant to support the 

Massachusetts Senior Medicare Patrol (MASMP) project. The goal is to continue to broaden 

and increase its outreach and education efforts throughout the state to reach low income, 

vulnerable, isolated, and limited English-speaking (LEP) populations about their health 

benefits eligibility, and how to identify Medicare and Medicaid errors, fraud and abuse. The 

objectives are: 1) to foster national and statewide program coverage; 2) to improve 

beneficiary education and inquiry resolution for other areas of health care fraud; 3) to foster 

national program visibility and consistency; to improve the efficiency of the SMP Program, 

increasing the results for both operational and quality measures; and 4) to target training and 

education to isolated and hard-to-reach populations. The expected outcomes are: 1) an 

increased linguistic capacity of the Massachusetts Serving Health Insurance Needs of Elders 

(SHINE) Program in the 13 regional SHINE programs; 2) an increased number of SHINE 

counselors in the 13 regional programs; 3) increased outreach, education services, and 

benefits counseling to at least 250,000 beneficiaries across the state; and 4) LEP populations 

reached throughout Massachusetts through a multi-pronged, multi-ethnic media campaign. 

Products include website; training materials in different languages; and reports, as required. 




Project Title: Senior Medicare Patrol Program 



Michigan Medicare/Medicaid Assistance Program, Inc. (MMAP) 

6105 W. St. Joseph Hwy. Suite 204 


Contact: 

Jo Murphy 

Tel. No. (517) 886-1242 

Email: jo@mmapinc.org 


Fiscal 

Year 

Funding 

Amounts 









Total $640,000 


The Michigan Medicare/Medicaid Assistance Program (MMAP) picked up the third year of a 

three-year grant, originally awarded to the Area Agencies on Aging Association of Michigan. 

The goal for this continuation grant, the Michigan Medicare\Medicaid Assistance Program 

(MMAP), is to increase prevention, detection, and reporting of Medicare and Medicaid fraud, 

errors, and abuse by Michigan's 1.5 million Medicare beneficiaries. MMAP will achieve this 

goal through statewide education, outreach, and prevention efforts. The objectives are: 1) to 

foster national and statewide program coverage; 2) to improve beneficiary education and 

inquiry resolution for other areas of heath care fraud; 3) to foster national program visibility 

and consistency; 4) to improve the efficiency of the Senior Medicare Patrol (SMP) program 

while increasing results for both operational and quality measures; and 5) to target training 

and education to isolated and hard-to-reach populations. Expected outcomes: 1) increased 

savings to Medicare, Medicaid, and individual beneficiaries; 2) increased number of active 

volunteers who counsel beneficiaries and conduct outreach about Medicare fraud, errors, and 

abuse; 3) increased number of beneficiaries who know how to prevent, detect, and report 

Medicare fraud, errors, and abuse; 4) increased referrals from state and local partners; and 

5) increased and improved SMP services. Products will include: summary of innovative best 

practices in reaching traditionally underserved populations; press releases, flyers, and 

outreach presentations; SMP brochures; training materials; Internet-based SMP training and 

certification module. 




Project Title: Minnesota's Senior Medicare Patrol 2009-2012 





PO Box 64976 

St. Paul, MN 55164-0976 

Contact: 

Krista K. Boston 

Tel. (651) 431-7415 



Fiscal 

Year 

Funding 

Amounts 









Total $360,000 


This is a continuation of a three-year health care anti-fraud demonstration project in 

partnership with the seven Minnesota Area Agencies on Aging and related organizations 

serving hard-to-reach populations. The goal of the project is to empower individuals to 

identify and report instances of error, fraud and abuse in the health care system with 

emphasis placed on Medicare and Medicaid programs. Objectives of the project are to: 1) 

foster national and statewide Senior Medicare Patrol (SMP) coverage; 2) improve beneficiary 

education and inquiry resolution for other areas of health care fraud; 3) foster national 

program visibility and consistency; improve the efficiency of SMP, while increasing results for 

operational and quality measures; 4) and target training and education for hard-to-reach 

populations. Expected outcomes are: 1) an increased number of Minnesotans who receive 

services from the Senior LinkAge Line who are aware of fraud, abuse and error issues and 

know how to identify and report them; 2) increased number of consumers and professionals 

from helping agencies who know where to go for objective help with questions regarding 

health care fraud, errors and abuse; 3) a decreased number of individuals who experience 

confusion and frustration when trying to report and resolve fraud, abuse and errors; and 4) 

increased knowledge, skills and confidence of Senior LinkAge Line staff/volunteers to provide 

comprehensive health insurance counseling, as it pertains to health care fraud, abuse and 

error. Products will include a new interactive Web site; secure instant message software and 

voiceover Internet Protocol capability; automated statewide tracking of health care fraud, 

abuse and error grievances; virtual volunteer coordinator reference handbook; a cookbook; 

and a report, as required. 




Project Title: Senior Medicare Patrol (SMP) Project 



Mississippi Department of Human Services 


750 North State Street 


Contact: 

Dan George 

Tel. (601-359-4929) 

Email: Danny.George@mdhs.ms.gov 

AoA Project Officer: Joyce R. Robinson-Wight 

Fiscal 

Year 

Funding 

Amounts 









Total $350,000 


This is a continuation of a three-year Senior Medicare Patrol (SMP) grant to the Mississippi 

Department of Human Services (MDHS), Division of Aging and Adult Services (DAAS), to 

establish a statewide network of trained volunteers serving in their communities to educate 

and assist seniors in identifying and combating health care fraud, error and abuse. As the 

State Unit on Aging, DAAS will use oversight and coordination to provide services to 

Mississippi's older population through a system of Area Agencies on Aging (AAAs). The 

three-year project incorporates statewide partnerships and sub-grants to serve seniors in 

Mississippi's 82 counties. The project goal is to educate Mississippi's population to 

recognize, report, and reduce fraud and abuse of Medicare recipients. The objectives are to: 

1) foster national and statewide program coverage; improve beneficiary education and inquiry 

resolution for other areas of health care fraud; 2) foster national program visibility and 

consistency; 3) improve efficiency of the SMP program, while increasing results for both 

operational and quality measures; 4) and target training and education to isolated and hardto-reach 

populations. The expected outcomes are: 1) increased number of trained 

volunteers; 2) increased number of volunteer presentations; 3) increased number of 

Mississippians educated in fraud and abuse awareness; 4) increased number of Medicare 

abuse/error complaint calls; and 5) increased amount of dollars saved to Medicare, Medicaid 

or beneficiaries. Products will include required reports, including evaluation results; lowliteracy 

literature; and a volunteer training manual. 




Project Title: The Missouri Senior Medicare Patrol 



District III Area Agency on Aging 

PO Box 1078 

Warrrensburg, MO 64093 

Contact: 

Diana Hoemann 

Tel. (660) 747-3107 

Email: dhoemann@goaging.org 


Fiscal 

Year 

Funding 

Amounts 









Total $359,956 


This is a continuation of a three-year grant to the District III Area Agency on Aging (AAA) for 

support of the Missouri Senior Medicare Patrol project (SMP). The goal of the Missouri SMP 

is to increase the awareness of Medicare and Medicaid error, fraud, and abuse among 

beneficiaries, their caregivers, home health and in-home workers, and hard-to-reach 

populations in the state of Missouri. The objectives are to: 1) conduct a statewide media 

campaign that semi-annually will focus on a topic of interest to Medicare/Medicaid recipients; 

2) refine and consolidate the training materials needed to train SMP volunteers; 3) contract 

with each Missouri AAA and the Missouri state prescription assistance program to provide 

volunteer support and training; 4) utilize the SMP Coalition's expertise to provide direction 

and support for the project; 5) develop an educational series focused on home health care 

and in-home care workers that will increase the ability of these professionals to recognize 

and report potential fraud and abuse to the appropriate agency, as well as distribute fraud 

and abuse information to their clients; and 6) collaborate with AAA's, local community groups 

and the state Office on Minority Health to reach targeted hard-to-reach populations. 

Expected outcomes are: 1) two retired senior volunteers will conduct activities to educate 

beneficiaries about potential fraud and abuse in each county in Missouri; 2) every county in 

the state will conduct a minimum of one group presentation and one media event; and 3) 

beneficiary inquiries about health care error, fraud and abuse will increase by 25% in areas 

targeted for minority outreach. Products will include educational toolkits, articles for 

publication, and a final report. 




Project Title: Montana Medicare Waste Project 



Missoula Aging Services 

337 Stephens Ave 

Missoula, MT 59801 

Contact: 

Renee Labrie-Shanks 

Tel. (406) 728-7682 

Email: rlabrie@missoulaagingservices.org 


Fiscal 

Year 

Funding 

Amounts 









Total $1,040,000 


This is a continuation of the Medicare Waste Project of the Missoula Aging Services, which 

will build on its nine years of experience in outreach and education to Medicare beneficiaries 

on the issues of waste, fraud and abuse and general consumer healthcare fraud through the 

Senior Medicare Patrol (SMP). The goals are to identify, report and reduce errors, fraud and 

abuse within the Medicare and Medicaid systems and focus on home health care, Medicaid 

and Medicare. The objectives are to: 1) inform and educate Medicare beneficiaries 

statewide by May 31, 2011 to identify potential healthcare error, fraud and abuse; 2) 

maintain 100 older adults as educators, counselors and advocates for Medicare beneficiaries, 

their families and the public; 3) enhance and expand relationships and collaborations with 

relevant state agencies and organizations on the issues of consumer healthcare fraud and 

Medicare/Medicaid; and 4) produce a library of self-training CD's for volunteers as well as 

beneficiaries. Expected outcomes are: 1) a higher level of beneficiary understanding, 

empowering them to identify and report healthcare waste, fraud and abuse, as demonstrated 

by survey returns; 2) an increased number of professional outreach partnerships statewide, 

including SMP, resulting in a more recognizable message; and 3) a greater number of 

volunteers receiving consistent and timely training. Products will include project reports, as 

required; abstracts for state and national conferences; Montana- specific SMP brochures, 

healthcare journals and a website; a library of self-training CD's; ads and articles for 

publication; and training manuals for partners and volunteers. 




Project Title: Nebraska Senior Medicare Patrol (SMP) Project 




Medicaid and Long Term Care 

PO Box 95026 

Lincoln, NE 68509 

Contact: 

Madhavi Bhadbhade 

Tel. (402) 471-2309 

Email: madhavi.bhadbhade@nebraska.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $360,000 


This is a continuation of a three-year grant to the Nebraska Office of Long Term Care (LTC) 

Ombudsman to support the Senior Medicare Patrol (SMP) program, Nebraska ECHO Project 

(Educating and Empowering Consumers of Healthcare Organizations). The goal of the 

ECHO Project is to increase awareness among Nebraska's beneficiaries on how to identify, 

report and prevent Medicare and Medicaid fraud, error and waste and to empower and assist 

them in protecting their rights. This includes the right to be billed accurately for services 

received and to not be victimized by fraud schemes. The objectives of the Nebraska SMP 

are to: 1) disseminate project information to beneficiaries, their caregivers, and the general 

public; 2) recruit, train and support qualified volunteers and enlist their efforts on behalf of 

beneficiaries; 3) develop and maintain a network of partnerships that will work together to 

eliminate healthcare fraud, error and waste; 4) provide outreach and advocacy to the most 

vulnerable of beneficiaries; and 5) provide targeted education to hard-to-reach populations. 

The expected outcomes of this project are: 1) beneficiaries will have an increased 

awareness of healthcare fraud, error and waste, and initiate positive changes in their 

behavior; 2) additional volunteers will be recruited and trained; and 3) an increased number 

of inquiries and complaints will be resolved or result in some action, including the savings or 

recoupment of healthcare dollars. The products from this project will include educational and 

promotional materials; a consumer website; and a summary of project data and 

accomplishments. 







Nevada Office of the Attorney General 

555 East Washington Ave. #3900 

Las Vegas, NV 89102 

Contact: 

Jo Anne Embry 

Tel. No. (702) 486-3154 

Email: jembry@ag.nv.gov 

AoA Project Officer: Dennis E. Dudley 

Fiscal 

Year 

Funding 

Amounts 









Total $360,000 


This is a continuation of a three-year grant to the Nevada Office of the Attorney General. The 

goal is to increase awareness of Medicare, Part D and Medicaid fraud, waste, and abuse. 

The objectives of the Nevada Senior Medicare Patrol (SMP) project are to: 1) create training 

manuals and develop new materials with the new logo and tag line, and culturally competent 

materials for non-English speaking and Nevada's rural populations; 2) maximize partner 

collaborations in order to improve outreach to Hispanic and rural populations; and 3) increase 

complaints to the program through the increased outreach; and incorporate the SmartFacts 

system to maximize program progress reporting. Expected outcomes are: 1) increased 

complaints to our state-wide hotline; and 2) increased awareness of issues involving 

Medicare, Medicare, Part D, and instances that may point to fraud, error or abuse. The 

products will include brochures; training modules; placemats, key chains, pens, pencils, jar 

openers, notepads, refrigerator magnets, and required reports. 







New Hampshire Department of Human Services 



Contact: 

Karol Demon 

Tel. (603) 271-4925 

Email: kdermon@dhhs.state.nh.us 


Fiscal 

Year 

Funding 

Amounts 









Total $360,000 


This is a continuation of a three-year grant to the New Hampshire Department of Health and 

Human Services, Bureau of Elderly and Adult Services (BEAS) for support of a Senior 

Medicare Patrol (SMP) project. The goal of the project is to recruit, train and manage a 

network of volunteers and counselors statewide to educate Medicare beneficiaries and their 

families about health care error, fraud and abuse. The objectives are to: 1) foster statewide 

and local SMP program awareness; 2) provide outreach and education on health care fraud 

and abuse; 3) conduct targeted outreach and assistance to people who are hard to reach; 

and 4) improve operational efficiencies and ensure consistent quality of reporting systems. 

Expected outcomes are: 1) increased statewide awareness of the Senior Medicare Patrol 

project; 2) increased number of Medicare beneficiaries reached who are homebound, living in 

isolated or rural areas, who have low literacy, limited income and/or living with disabilities or 

chronic illnesses; 3) more improved operationally efficient program; and 4) an increase in the 

number of knowledgeable beneficiaries on matters of health care fraud, error and abuse and 

other scams. Products will include: brochures; newsletters; PowerPoint presentations; and 

project reports and evaluation, as required. 




Project Title: Senior Medicare Patrol (SMP) of New Jersey 



Jewish Family and Vocational Services of Middlesex County 

32 Ford Ave, 2nd Floor 

Milltown, NJ 08850 

Contact: 

Charles Clarkson 

Tel. No. (732) 777-1940 

Email: CharlesC@jfvs.org 

AoA Project Officer: Barry Klitsberg 

Fiscal 

Year 

Funding 

Amounts 









Total $1,040,000 


This is a continuation of the Jewish Family and Vocational Services (JFVS) of Middlesex 

County grant to support a Senior Medicare Patrol (SMP) project designed to improve the 

quality of healthcare for senior citizens in New Jersey. The goal is to reach out and to 

provide information so that seniors (with an emphasis on African- Americans and the 

homebound population) can take the appropriate steps to protect themselves from becoming 

victims of fraud. The objectives are to: 1) utilize staff and volunteers in order to reach as 

many seniors of the State as possible; 2) partner with aging services professionals, law 

enforcement personnel and others to promote awareness of Medicare/Medicaid fraud; 3) 

develop and disseminate consumer educational materials about and to prevent 

Medicare/Medicaid fraud; 4) provide counseling and serve as consumer advocates in 

resolving billing disputes and errors; and 5) receive and resolve complaints of suspected 

fraud and to make referrals to appropriate agencies. The expected outcomes are that 

seniors in New Jersey will: 1) become aware of the extent of fraud in the Medicare and 

Medicaid programs; 2) review their Medicare Summary Notices to ensure that they are 

receiving the services for which Medicare is paying; 3) take the necessary steps to call their 

providers to correct any billing disputes and errors; and 4) report suspected cases of fraud to 

JFVS-SMP and to other agencies. The products will include semiannual and final reports; 

Group Session Post Survey; press releases and articles for publication; television interviews; 

public service announcements on radio and television; and brochures, flyers, and tip sheets. 




Project Title: Senior Medicare Patrol – New Mexico Seniors Saving 

Medicare/Medicaid 



New Mexico Aging and Long Term Services Department 

2550 Cerrillos Road 


Contact: 

Deborah Armstrong 

Tel. (505) 476 - 4755 

Email: debbie.armstrong@state.nm.us 

AoA Project Officer: Lisa Theirl 

Fiscal 

Year 

Funding 

Amounts 









Total $1,040,000 


This is a continuation grant to the New Mexico Aging and Long Term Services Department to 

support a Senior Medicare Patrol (SMP) project. The goal of the NM Aging and Long-Term 

Services Department Senior Medicare Patrol (SMP) program is to strengthen client selfadvocacy 

by increasing beneficiaries' knowledge of their rights and their ability to recognize 

and react to Medicare and Medicaid (M/M) error, fraud, and under/over utilization. The 

objectives are to: 1) continue to foster national and statewide program coverage; 2) improve 

beneficiary education and inquiry resolution for many areas of health care fraud, with special 

focus in New Mexico on Medicaid waste, fraud and abuse and Medicaid long-term care 

initiatives; 3) continue to foster national program visibility and consistency; 4) increase 

operation and quality measures to improve the efficiency of the SMP program; and 5) target 

training and education to isolated and hard-to-reach populations. Expected outcomes are: 1) 

an established presence and an active volunteer base in the greater Albuquerque, Santa Fe 

and Las Cruces areas and in some smaller communities in the state; 2) recruitment of 

Spanish and Navajo speaking volunteers; 3) a toll-free help line accessible throughout the 

state; 3) expanded knowledge of Medicare/ Medicaid waste, fraud and abuse through most of 

the state; 4) an increase in the number of volunteers proficient in Medicare/Medicaid issues; 

5) a high-percentage of seniors informed about Part D Medicare program enrollment 

procedures; and 6) the recovery of thousands of dollars. Products will include a new 

Medicare/Medicaid packet; an updated volunteer training manual; an on-line volunteer 

training module; and on-line fraud alerts specific to the basics of Medicare, Medicaid, home 

health care, and Medicare prescription drug coverage and Medicare health plans. All 

products will be bilingual. 




Project Title: New York State Senior Medicare Patrol Project 




Health Benefits and Economic Section 


Albany, NY 12223-1251 

Contact: 

Marcas Harazin 

Tel. No. (518) 473-5177 


AoA Project Officer: Baryy F. Klitsburg 

Fiscal 

Year 

Funding 

Amounts 









Total $360,000 


This is a continuation of a three-year grant to New York State Office for the Aging to support 

a Senior Medicare Patrol (SMP) program. The goal of this project is to ensure health care 

fraud control outreach and education in aging, social, health and law enforcement networks. 

The objectives are to: 1) expand already established programs; 2) expand the number of 

certified long-term care ombudsman and health insurance information counselors who are 

trained SMP volunteers; 3) renew the contract with National Government Services, Inc. 

(NGS) to continue its role of maintaining a statewide toll-free hotline; 4) work cooperatively 

with the NY Connects Program, which is an ADRC-type model with regard to staff 

development and community presentations; 5) continue work with New York State Office of 

Medicaid Inspector General and the New York State Attorney General Medicaid Fraud Unit to 

increase enforcement and prosecution of fraud, error and abuse cases; 5) work with long 

standing and new partners who are committed to reaching those in most economic and social 

need, who are particularly vulnerable to health care fraud, error and abuse due to social 

isolation; and 6) develop multiple ways to disseminate SMP through a variety of conferences 

and symposiums. Expected outcomes are to: 1) expand the network of SMP volunteers to 

include providers and seniors across residential and community-based systems; 2) increase 

the awareness of isolated seniors; and 3) reactivate the state workgroup. Products include a 

final report consisting of a model for replication; a legislative proposal for whistleblower 

protection; data collection; a hotline number for general information; and updated outreach 

materials. 




Project Title: North Carolina Senior Medicare Patrol Program 



North Carolina Department of Insurance 

11 South Boylan Avenue 


Contact: 

Carla S. Obiol 

Tel. (919) 807-6900 

Email: carla.obiol@ncdoi.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $360,000 


This is a continuation of a three-year grant to the Seniors' Health Insurance Information 

Program (SHIIP) to continue the North Carolina Senior Medicare Patrol (NCSMP) program. 

The goal of this program is to reduce Medicare/Medicaid error, fraud and abuse through 

statewide coordinated efforts of educational and promotional activities and to encourage 

reporting by Medicare/Medicaid beneficiaries and caregivers. The objectives are to: 1) 

provide and expand education/promotional activities to Medicare/Medicaid beneficiaries, 

caregivers, and traditionally underserved populations; 2) recruit, train and retain volunteers; 

3) received and resolve complaints of error, fraud and abuse; 4) network with statewide 

partners to serve as advisors, trainers and to provide counseling assistance with resolving 

error, fraud and abuse issues; 5) develop and disseminate educational materials to the SMP 

Resource Center and projects; 6) participate in the SMP complaints management system and 

integration strategies; and 7) evaluate program outcomes. The expected outcomes are: 1) 

increased number of reported and resolved complaints; and 2) increased number of 

educational materials and strategies that will serve as examples for other SMP projects. The 

products from the project are written reports and evaluations; educational, promotional and 

training materials; and education and outreach activities. 




Project Title: North Dakota Senior Medicare Patrol (II) Project 



Minot State University 

North Dakota Center for Persons with Disabilities 

500 University Ave W 

Minot, ND 58707 

Contact: 

Linda Madsen 

Tel. (701) 858-3424 

Email: linda.madsen@minotstateu.edu 


Fiscal 

Year 

Funding 

Amounts 









Total $360,000 


This is a continuation of a three-year grant to Minot State University (MSU). The MSU 

Community Outreach Services of the N. Dakota Center for Persons with Disabilities (NDCPD) 

will collaborate with AARP, ND Disability Advocacy Consortium (NDDAC), Retired Senior 

Volunteer Program (RSVP), and the ND Senior Health Insurance Counseling (SHIC) program 

to help ND rural seniors identify and report Medicare errors, fraud & abuse through a Senior 

Medicare Patrol (SMP) program. The goal of ND SMP is to help all ND seniors, including 

those in the most rural counties and those with disabilities, review their Medicare bills to 

assure that no errors, fraudulent charges or abuse have occurred. Local volunteers, regional 

volunteer coordinators and disability adapted curricula will be utilized to educate underserved 

Medicare beneficiaries, including seniors in frontier counties, and individuals with disabilities 

on Medicare and Medicaid. Objectives are to: 1) increase steering committee membership 

for comprehensive state input; 2) sustain 8 regional volunteer coordinators and at least 80 

volunteers statewide; 3) continue training regional coordinators and volunteers to provide 

beneficiary assistance; 4) implement SMP activities for at least 400 beneficiaries, including 

information dissemination, group training, and one-on-one beneficiary education and inquiry 

processes; 5) provide ongoing guidance and technical assistance to meet individual needs; 

and 6) evaluate the impact of the ND SMP project. Expected outcomes include: 1) greater 

public awareness of potential Medicare errors, fraud or abuse; 2) increased skills in 

examining Medicare charges; and 3) increased inquiries and resolution of errors, fraud and 

abuse. Products will include a final report with evaluation results; an accessible website; 

web-based training materials with CD-ROM; adaptable and disability accessible volunteer 

and constituent training materials; paper and electronic presentations; and professional 

articles. 




Project Title: Ohio Seniors Fight Fraud 




7162 Reading Rd., suite 1150 


Contact: 


Tel. No. (513) 458-5506 



Fiscal 

Year 

Funding 

Amounts 









Total $927,000 


This is a continuation of a grant to Pro Seniors to continue its Senior Medicare Patrol Project, 

Ohio Seniors Fight Fraud (OSFF), in Southwestern Ohio. The goal of this project is to 

empower beneficiaries and consumers to prevent health care fraud through outreach and 

education. The objectives are to: 1) establish SMP program coverage in all counties through 

strategic partnerships; 2) increase beneficiary education and inquiry resolution regarding 

Medicaid fraud; 3) foster national program visibility and consistency by enhancing the 

capability of the Aging and Disability Resource Centers and other community-based 

organizations to identify and refer health care fraud to Ohio SMP (OSMP); 4) improve the 

efficiency of Ohio SMP through effective use of SMARTFACTS; and 5) use creative outreach 

strategies to reach isolated and hard-to-reach populations, including low-income, rural and 

limited English-speaking individuals. The anticipated outcomes for the coming year include: 

1) recruiting and training 15 additional volunteers; and 2) educating at least 5,000 Medicare 

beneficiaries and caregivers, including 800 rural and 300 limited English-speaking 

populations, about health care fraud and inquiry resolution. The products of this project are: 

required reports, post surveys, volunteer newsletters, the health care fraud presentation, 

educational handouts, Personal Health Care Journals, and radio public service 

announcements. 




Project Title: SUMMIT Medicare/Medicaid Fraud, Abuse and Waste Reduction 



Oklahoma Insurance Department 

Senior Health Insurance Information Program Division 

Five Corporate Plaza 

3625 NW 56th Street, Suite 100 


Contact: 

Lisa B. Gober 

Tel. (401) 521-6632 

Email: lisa.gober@oid.ok.gov 

AoA Project Officer: Lisa J. Theirl 

Fiscal 

Year 

Funding 

Amounts 









Total $1,020,000 


This is a continuation of a grant for the Senior Medicare Patrol (SMP) program, Summit 

Medicare/Medicaid Fraud, Abuse and Waste Reduction Program (SUMMIT). The goal is to 

reduce Medicare/Medicaid fraud, abuse and waste in Oklahoma. Objectives are to: 1) 

provide fraud information to the general public (beneficiaries, family members, caregivers) 

through community presentations, public education, SMP training, with emphasis on 

geographically isolated rural/frontier elders; 2) provide Temporary Assistance to Needy 

Families (TANF) recipients through the Literacy Resource Office's Life Skills module; 3) 

assist isolated elders through home delivered meals by utilizing the Oklahoma Senior Center 

Association, and SUMMIT, SHICP, and AARP volunteers; 4) educate college/university 

students through Oklahoma Campus Compact Service Learning; 5) inform Hispanic elders 

through Hispanic Chambers of Commerce; and 6) educate American Indians through 

Oklahoma Indian Council on Aging. The expected outcomes are: 1) TANF recipients learn 

civic responsibility in reducing Medicaid fraud; 2) more college/university students realize the 

urgency to preserve Medicare/Medicaid for future generations; and 3) all Oklahomans, 

including Hispanics, American Indians, isolated rural/frontier and homebound beneficiaries 

learn self-protection against healthcare fraud. Products include training/resource manual; 

brochures and resource flyers; lesson plan for Oklahoma Literacy Council Life Skills in audio 

and visual; fraud booklet written at 4th - 6th grade reading levels; a presentation for 

college/university Service Learning Coordinators; handouts in Spanish; and required reports, 

including evaluation results. 




Project Title: Oregon Senior Medicare Patrol 




Senior and Disabled Services 

3420 Cherry Ave NE, Suite 140 

Salem, OR 97303-5328 

Contact: 

Victoria L. Weld 

Tel. (503) 934-6068 

Email: victoria.l.weld@state.or.us 


Fiscal 

Year 

Funding 

Amounts 









Total $1,040,000 


This is a continuation grant to the Oregon Department of Human Services to support the 

Senior Medicare Patrol (SMP) project, in collaboration with the Oregon Senior Health 

Benefits Assistance Program (SHIBA), the Oregon Home Care Commission, the Governor's 

Commission on Senior Services, AARP, and the Oregon Department of Justice. The goals 

are to: 1) continue to provide information, outreach, education, resources and advocacy 

through utilization of retired professionals as volunteers to combat Medicare/Medicaid (M/M) 

errors, fraud, and abuse; 2) educate hard-to-reach M/M beneficiaries and those most 

vulnerable to elder rights violations by training in-home caregivers; and 3) enhance outreach 

to tribal and minority communities. The objectives are to: 1) improve SMP coverage area by 

gaining volunteers in Oregon's more rural areas through existing partnerships and new 

partnerships with retiree organizations and hospitals; 2) conduct targeted outreach to dualeligible 

clients to more fully educate them regarding their benefits, fraud and abuse; 3) 

increase the SMP presence at the beneficiary level through direct beneficiary contacts, 

including distribution of the Oregon SMP newsletter; and 4) improve efficiencies in the 

program by bringing the program into a larger Medicare unit in the Senior and People with 

Disabilities Division. The expected outcomes of the project are 1) an increase in the number 

of volunteers and volunteer sponsoring organizations; and 2) an increased number of clients 

educated about fraud, waste and abuse. The products will include a training product that can 

be downloaded from the web for volunteers and others to access at their convenience, and 

required reports. 




Project Title: Pennsylvania Senior Medicare Patrol (SMP) 



Center for Advocacy for the Rights Interests of Elders 

100 S. Broad Street, Suite 1500 


Contact: 

Diane Menio 

Tel. (267) 546-3434 

Email: menio@carie.org 


Fiscal 

Year 

Funding 

Amounts 









Total $360,000 


This is continuation of a three-year grant to the Center for Advocacy for the Rights and 

Interests of the Elderly (CARIE) to support a Senior Medicare Patrol (SMP)project for the 

state of Pennsylvania (PA-SMP). The goal is to detect, combat, and increase public 

awareness of health care fraud and abuse throughout the state of Pennsylvania, thereby 

reducing the incidence of such practices. The objectives are to: 1) increase program 

visibility and awareness in Pennsylvania through onsite outreach activities; 2) achieve 

comprehensive statewide coverage through a partnership with the state health information 

program (SHIP); 3) recruit and train retired beneficiaries to provide outreach and education to 

their peers; 4) provide consultation and complaint resolution to consumers; 5) provide 

measurable outcomes and demonstrate the project's effectiveness; and 6) utilize partners 

and an advisory committee to build a strong program. The expected outcomes include: 1) 

several thousand individuals reached at health fairs and presentations leading to increased 

awareness of fraud and its prevention; 2) a presence in each of Pennsylvania's 67 counties 

through newsletter articles, consumer education materials and giveaways, and direct contact 

with consumers; 3) new volunteers who will be trained on health care fraud detection and 

prevention; 4) increased numbers of consumers assisted with complaint resolution; and 5) an 

increase in reporting and savings to the Medicare program. Products will include a 

semiannual and final reports, as required; consumer education materials, including flyers, 

bookmarks, promotional items, and health care calendars; consumer materials targeted to 

non-English speakers, i.e., flyers in Spanish, Chinese, etc.; volunteer newsletters and alerts; 

and a comprehensive website. 




Project Title: Puerto Rico Alert to Fraud Project-Senior Medicare Patrol 

Project (SMPP) 


Puerto Rico Governor’s Office of Elderly Affairs 

P.O. Box 191179 

San Juan, PR 00919-1179 

Contact: 

Rosanna Lopez 

Tel. (787) 721-6121 




Fiscal 

Year 

Funding 

Amounts 









Total $1,040,000 

This is a continuation of a grant to the Puerto Rico Office of the Ombudsman for the Elderly 

to support a Senior Medicare Patrol (SMP) project. The goal of the Puerto Rico Alert to 

Fraud is to enhance the capacity of the Puerto Rico SMP, Alert to Fraud project (PR-Alf/SMP) 

to recruit and train volunteers to educate Medicare and Medicaid beneficiaries, caregivers 

and their families to detect and report health care fraud. The objectives are to: 1) foster the 

national and program coverage; 3) improve beneficiary education and inquiry resolution for 

other areas of health care fraud; 4) foster program visibility to enhance its capacity to identify 

and refer suspected fraud; 5) improve consistency and accuracy in collecting and reporting 

program performance date; 6) improve the efficiency while increasing results for both 

operational and quality measures; and 7) ensure the training and education of targeted 

isolated and hard-to-reach populations. The expected outcomes are: 1) one major initiative 

per quarter in collaboration with Consortium members to produce anti-health care fraud 

strategies and activities; 2) volunteers and staff demonstrate at least 90% proficiency in 

knowledge relevant to prevention, detection, and reporting health care fraud; 3) at least 90% 

average on participants' evaluations during outreach educational activities; 4) 90% rate of 

compliance with performance objectives; and less 5) than 5% error rate in collecting and 

reporting program data in the SMARTFACTS system. Products from the project will include a 

final report; educational materials in Spanish; and outcome assessments of all strategies for 

outreach and education and web access to program information. 








74 West Road 


Contact: 

Aleatha Dickerson 

Tel. (401) 462- 0931 

Email: adickerson@dea.ri.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $360,000 


This is a continuation of a three-year Senior Medicare Patrol Project (SMP). The goals are to 

recruit and train volunteers to provide a comprehensive, coordinated statewide information 

and referral system to educate groups of Medicare/Medicaid beneficiaries, their families and 

professionals about Medicare/Medicaid fraud, error and abuse. The objectives are to: 1) 

utilize the Rhode Island Adult and Disability Resource Center (ADRC) known as "The Point" 

as the central Information and Referral access for persons concerned about SMP issues; 2) 

contract with six regional agencies to help coordinate SMP activities; 3) partner with State 

Health Insurance Information Program (SHIP) by conducting a variety of co-sponsored 

educational community outreach events; 4) recruit more counselors than expected; improve 

program visibility and impact (particularly in Providence); 5) provide counseling to non- 

English speakers (especially Spanish); 6) professionalize the training process of SMP 

counselors through structured certification; and 7) access Department of Elderly Affairs' 

contacts and public awareness mechanisms in communicating the SMP message to the 

network and relevant community members. As with the successful activities of the past year, 

the expected outcome will be increased program centralization to assure that achievable and 

measurable activities occur every week. Products from this project are: a final report, 

including evaluation results; a resource guide; press releases; newspaper articles; brochures; 

and abstracts for national conferences. 




Project Title: Senior Fraud Counseling 







Contact: 

Gloria McDonald 

Tel. (803) 734-9902 

Email: mcdong@aging.sc.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $350,000 


This is a continuation of a three-year grant for the Senior Medicare Patrol (SMP) program 

administered by the Lieutenant Governor's Office on Aging-Division of Aging Services. The 

SMP program provides services that address fraud in Medicare/Medicaid through a statewide 

aging network with Area Agencies on Aging (AAAs) as service providers in each of the ten 

regions of the state. The goal of the Senior Medicare Patrol project is to provide statewide 

fraud education and seminars to individuals and groups about Medicare and Medicaid fraud, 

error and abuse. The objectives are to: 1) conduct ongoing seminars; 2) submit fraud alerts 

to the media, 3) make home visits and telephone contacts to inform beneficiaries and the 

public at large about Medicare health care fraud; 4) establish a system for individuals to 

report suspected fraud/abuse and errors; 5) recruit, train, and retain counselors to help 

individuals review and understand health care summary notices; 6) collaborate with aging 

network, PalmettoGBA Benefits Integrity Unit and the Attorney General's Office to train 

counselors and to serve as a clearinghouse for suspected fraud; 7) and disseminate project 

information, literature and promotional items. The outcomes of the project are: 1) to reach 

diverse beneficiary population with awareness of fraudulent tactics, and 2) increase reading 

of or have caregivers review Medicare Summary Notices for fraud and errors. Products 

include semi-annual reports; final report, including evaluation results; and educational and 

promotional materials. 




Project Title: South Dakota Senior Medicare Patrol Program 



East River Legal Services Corporation 

335 N. Main Ave., #300 

Sioux Falls, SD 57104 

Contact: 

Candise H. Gregory 

Tel. (605) 336-2475 

Email: gregory.candise@att.net 

AoA Project Officer: Courtney Hoskins 

Fiscal 

Year 

Funding 

Amounts 









Total $360,000 


The East River Legal Services (ERLS) supports this continuation grant of the three-year 

South Dakota Senior Medicare Patrol (SMP) project in collaboration with the South Dakota 

State Health Insurance Program (SHIP), Cooperative Extension Services, South Dakota 

Division of Insurance and South Dakota Attorney General's Office. The goal of the project is 

to provide education and information relating to Medicare fraud, as well as other types of 

health care and consumer fraud. The objectives are to: 1) recruit and train volunteers from 

the network; 2) educate seniors about Medicare benefits and how to recognize and report 

suspected fraud, error, waste and abuse; 3) expand outreach to seniors in all 66 counties of 

the state; 4) keep seniors advised in a timely manner of issues affecting their health and wellbeing; 

and 5) increase inquiry resolution for seniors. The expected outcome is an increase in 

client contacts and households reached through media events. Products will include a final 

report of project results and statistical information; an interactive website; the Medicare 

Advantage handout; scam alerts; and a targeted newspaper column and additional self-help. 




Project Title: Tennessee Senior Medicare Patrol Project 



Upper Cumberland Development District 

1225 S. Willow Avenue 

Cookville, TN 38509 

Contact: 

LaNelle Godsey 

Tel. (931) 432-4111 

Email: lgodsey@ucdd.org 


Fiscal 

Year 

Funding 

Amounts 









Total $1,080,000 


This is a continuation of a grant to the Upper Cumberland Development District/Area Agency 

on Aging and Disability (AAAD) to administer a three-year Senior Medicare Patrol (SMP) 

program focusing on fraud, waste, and abuse monitoring in the Medicare and Medicaid 

systems. The goal is to enhance and expand the existing Tennessee Senior Medicare Patrol 

Project by focusing on recruitment of qualified volunteers, strengthening our community 

partnerships and expanding our joint Senior Medicare Patrol project (SMP) and State Health 

Insurance Assistance Program (SHIP) Advisory Board. The objectives are to: 1) expand and 

enhance the joint SMP/SHIP Advisory Board; 2) hold statewide volunteer trainings to 

increase the volunteer base; 3) develop new outcome measurement tools; 4) produce a 

quarterly newsletter; 5) enhance the SMP website; 6) enhance media exposure; 7) 

disseminate project information; and 8) provide semi-annual reports to AoA. The expected 

outcome is increased awareness of the Tennessee SMP program. Products from this project 

are required reports, including evaluation results; and magnifying glasses, fraud playing 

cards, and other volunteer recognition items. 




Project Title: Senior Medicare Patrol Project - MOD Squad 



Better Business Bureau Educational Foundation 

1333 West Loop South 

Houston, TX 77027-9116 

Contact: 

Candace Tywman 

Tel. No. (713) 341-6124 

Email: ctwyman@bbbhou.org 


Fiscal 

Year 

Funding 

Amounts 



FY2008 $180.000 






Total $915,000 


This is a continuation of a grant to the Better Business Bureau Education Foundation to 

accomplish and continue to implement a collaborative effort utilizing volunteers and 

community stakeholders educating Medicare and Medicaid beneficiaries to detect and report 

healthcare fraud, waste and abuse. The goal for the project is to combat Medicare fraud and 

waste by recruiting and training retired professionals as volunteer educators to reach other 

older adults throughout the Greater Houston area and empower them to become partners in 

the effort to end Medicare fraud, waste and abuse. The objectives are to: 1) develop and 

maintain collaborative efforts with eldercare agencies and service organizations; 2) engage 

older adults to actively participate in protecting themselves from consumer fraud; 3) recruit 

and train volunteers to provide education; 4) expand outreach to limited English-speaking 

populations; and 5) increase awareness and engage agencies and professionals in 

promoting the prevention of healthcare fraud. Expected outcomes are: 1) increased 

understanding of Medicare benefits and fraud; 2) increased detection and reporting of 

healthcare fraud; and 3) increased awareness of consumer fraud. Products will include: 

educational materials for limited English-speaking populations; tools to reach low-literate 

beneficiaries; and training tools for professionals. 




Project Title: Utah Senior Medicare Patrol (SMP) 





120 N 200 W, #325 

Salt lake City, UT 84103 

Contact: 

Darren Hotton 

Tel. (801) 538-4412 

Email: dhotton@utah.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $316,000 


This is a continuation of a three-year grant to Utah Legal Services to support a Senior 

Medicare Patrol (SMP) project. The goal of the three-year project is to educate and empower 

Utah seniors and caregivers to prevent and report health care fraud by recruiting and training 

volunteers to conduct outreach and education and to interact with law enforcement. The 

objectives are to: 1) increase outreach to the Native American population through our subgrantee, 

2) Utah State Ombudsman Program; 3) increase the quality and scope of 

community education events and one-on-one sessions; 4) increase the number of inquiries 

and rate of resolution of reported health care fraud; 5) gather data for grant reporting; and 6) 

increase statewide travel. The expected outcomes are: 1) an increased awareness of health 

care fraud following educational presentations and one-on-one sessions; and 2) an increased 

number of beneficiaries who read notices, report errors and seek assistance from this project. 

Products will include project reports, as required; training materials; evaluation results; 

website; brochures; and a monthly newsletter. 




Project Title: Vermont Senior Medicare Patrol (SMP) 



Community of Vermont Elders 

P.O. Box 1276 

Montpelier, VT 05641 

Contact: 

Anita Hoy 

Tel. (802) 229-4731 

Email: anita@vermontelders.org 

AoA Project Officer: Michael Barry 

Fiscal 

Year 

Funding 

Amounts 









Total $180,000 


This is a continuation of a three-year grant to provide a Senior Medicare Patrol (SMP) project, 

Community of Vermont Elders. The goals of the project are to: 1) build upon the current 

structure of collaborative efforts with professionals in Vermont's elder network who can assist 

with public education, identification of Medicare error and waste and referral; 2) continue to 

utilize the media as a primary educational strategy, which effectively provides useful resource 

information to isolated and homebound beneficiaries; 3) continue to identify opportunities to 

educate Vermonters about Medicare program benefits, rights and protections; and 4) develop 

an outreach and education strategy to reach people with disabilities. The objectives are to: 

1) continue collaborative agreement with AAAs; 2) collaborate with SHIP to form an 

educational strategy for people with disabilities; 3) continue collaboration with the National 

Senior Service Corps; 4) continue expansion of referral and reporting services; 5) 

identify/train and incorporate an intern as a designated program outreach assistant; and 6) 

strengthen/broaden representation and expertise on the Vermont SMP Advisory Council. 

The expected outcomes are: 1) a reduction in Medicare/Medicaid error, fraud and abuse; 2) 

increased number of referrals received; 3) an increase in the number of volunteers engaged 

in education; 4) an increase in the number of beneficiaries and providers educated; 5) 

addition of key stakeholders in Advisory Council; 6) increased reporting; and 7) increased 

public awareness about Vermont SMP and Medicare error, fraud and abuse. Products from 

this project will include a final report, including evaluation results; public service 

announcements; and educational materials. 







Virgin Islands Department of Human Services 

Knud Hansen Complex Building A 

Charlotte Amalie, VI 00802 

Contact: 

Michal Rhymer-Charles 

Tel. (340) 774-1166 

Email: mrhymercharles@dhs.gov.vi 


Fiscal 

Year 

Funding 

Amounts 









Total $150,000 


This is a continuation of a three-year grant to the Virgin Islands Department of Human 

Services. The grant supports a Senior Medicare Patrol (SMP) program which recruits and 

trains senior citizens, including retired professionals as volunteers, to educate Medicare and 

Medicaid beneficiaries and/or their caregivers on how to protect themselves from fraud and 

abusive health care practices. The primary goal of the SMP program is to continue to expand 

the program territory wide, through recruitment, outreach, referral, and follow-up. The 

objectives of the project are to: 1) identify target populations, such as seniors in isolated and 

hard-to-reach areas; 2) develop educational materials to serve the bilingual and culturally 

diverse and visually impaired, as well as those with limited literacy skills; 3) develop a 

reporting system to report and follow up on any suspected fraud or abuse; 4) implement 

program coverage strategies, such as web-based applications, media and outreach events; 

5) enhance beneficiaries' education through various collaborative efforts and group training 

sessions with statewide partners; and 6) establish outreach outcomes for seniors at eight 

senior citizen centers territory wide, caregiver support groups, senior independent living 

communities, and assisted living facilities. The expected outcomes are:an increased number 

of: 1) volunteers recruited; 2) training sessions; 3) beneficiaries reached, and 4) educational 

activities. Products will include required reports, including evaluation results; brochures; and 

educational materials. 




Project Title: Senior Medicare Patrol Program 



Virginia Association of Area Agencies on Aging 

24 East Cary Street, Suite 100 


Contact: 

Susan Johnson 

Tel. No. (804) 644-5628 

Email: sjohnson@thev4a.org 

AoA Project Officer: Carman D. Sanchez 

Fiscal 

Year 

Funding 

Amounts 









Total $1,020,000 


This is a continuation of a grant to the Virginia Association of Area Agencies on Aging (V4A) 

to manage a statewide Senior Medicare Patrol Project (SMP) to reduce public funds lost in 

Virginia due to Medicare/Medicaid error, fraud, and abuse. The goal of V4A is to provide 

education about health care fraud, error and abuse, and prevention tools to beneficiaries, 

family members and providers. The approach expands use of a toll-free hotline for 

questions, referrals, and the reporting of Medicare/Medicaid fraud; subcontracts with local 

area agencies on aging (AAAs) and Aging and Disability Resource Center (ADRC) programs 

for older volunteers to assist with public education and outreach activities; and collaborates 

with statewide organizations that reach target populations. Objectives are to: 1) disseminate 

80,000 Medicare Medicaid Protection Toolkits through AAAs with State Health Insurance 

Information Programs/Virginia Insurance Counseling Assistance Program Activities, TRIAD 

chapters, Senior Navigator Centers, local social services, and other partners; 2) train staff 

and volunteers statewide; establish systematic outreach plans to reach beneficiaries, 

caregivers, and residents in long-term care (LTC) facilities, and rural, low-income, and 

Hispanic populations; 3) collaborate with statewide organizations/agencies to enhance their 

participation in SMP related activities; 4) and enhance responses to callers' inquiries and 

complaints. The expected outcomes are: 1) an increased number of beneficiaries, 

caregivers, and family members will learn about health care fraud, preventing fraud, and 

reporting Medicare or Medicaid fraud; and 2) an increased number of referrals to SMP by 

way of statewide partners. Products from this project will include a Medicare/Medicaid fraud 

prevention toolkit; articles for media publication throughout the state; an updated website for 

public use; and a quarterly SMP communiqué for communication among AAA partners, and 

aging, health and consumer partners. 




Project Title: Senior Medicare Patrol Project Consortium 



Washington Office of the Insurance Commissioner 

State Health Insurance Benefits Advisors Helpline 

P.O. Box 40256 

Olympia, WA 98504 

Contact: 

Marijean Holland 

Tel. (360) 725-7091 

Email: MarijeanH@oic.wa.gov 


Fiscal 

Year 

Funding 

Amounts 









Total $1,040,000 


This is a continuation grant to the Washington State Office of the Insurance Commissioner's 

(OIC) Statewide Health Insurance Benefits Advisors (SHIBA) HelpLine Statewide Health 

Insurance Benefits Advisors (SHIBA) HelpLine to support a Washington State Senior 

Medicare Patrol (SMP) project. The goal of the project is to prevent Medicare and Medicaid 

fraud, abuse, and waste by educating consumers on how to better monitor what these 

programs pay for on their behalf, and to identify and report potential discrepancies. The 

objectives are to: 1) recruit, train, and place retired professional people to provide service; 2) 

provide public education, counseling and outreach to seniors and their caregivers and those 

enrolled in Medicaid; develop and distribute, via volunteers who specialize in fraud education 

and consumer protection, information statewide to the public targeting rural, diverse, and 

limited-English speaking populations; 3) develop effective fraud training curricula that 

supports high-quality service; 4) address the information gap by recruiting technologicallysavvy 

volunteers and ensuring appropriate resources are available to enter information 

directly into the SMARTFACTS system; and 5) develop and maintain community partnerships 

that increase program capacity and sustainability. The expected outcomes are: 1) Medicare 

and Medicaid beneficiaries and caregivers are better informed and educated on how to 

prevent, monitor, and report potential fraud and abuse; 2) more efficient tracking of fraud and 

abuse incidences and trends by partnerships; and 3) more trusted and competent volunteer 

networks to support rural, diverse, and limited-English speaking communities. Products will 

include semi-annual performance measures and financial reports; social marketing and public 

education materials, and specific fraud volunteer training materials. 




Project Title: West Virginia Senior Medicare Patrol Project 



AARP Foundation 



Contact: 

Julia Stephens 

Tel. (202) 434-2051 

Email: jstephens@aarp.org 



Fiscal 

Year 

Funding 

Amounts 









Total $1,040,000 

This is a continuation of a grant to the AARP Foundation, for support of the West Virginia 

Senior Medicare Patrol Project (SMP). The goal is to further reduce public funds lost to 

Medicare and Medicaid through error, waste, fraud and abuse by continuing to expand the 

efforts implemented in previous years. The project objectives are to: 1) recruit, train and 

support volunteer leaders and educators to provide education, training, and consultation 

about health care fraud and abuse to their peers in rural counties; 2) conduct a media 

campaign to promote the project and toll-free hotline using newspaper, radio, and television; 

2) provide education to Medicare and Medicaid beneficiaries; and 4) provide assistance 

through complaint resolution to those reporting suspected health care fraud and abuse. 

Expected outcomes are: 1) reduction in error, waste, fraud, and abuse in the delivery of 

health care services within Medicare and Medicaid; 2) increased number of volunteer led 

workshops, beneficiaries educated, complaints received, providers trained, and savings to 

the Medicare and Medicaid programs; and 3) an increase in the number of people reached 

through public relations and marketing activities. Products will include a training film aired on 

cable access television, and required project reports. 




Project Title: Wisconsin SMP Coalition of Wisconsin Aging Groups Senior 

Medicare Patrol Project 



Coalition of Wisconsin Aging Groups 

Legal Services 

2850 Dairy Drive, Suite 100 

Madison, WI 53718,-6742 

Contact: 

Bridget Merstad 

Tel. (608) 224-0606 

Email: bridgete@cwag.org 


Fiscal 

Year 

Funding 

Amounts 









Total $360,000 


This is a continuation of a three-year grant to the Coalition of Wisconsin Aging Groups' 

(CWAG) Elder Law Center to build on the successful volunteer and partnering programs of its 

nine-year Senior Medicare Patrol (SMP) grant ("the project") and Integration Grant by 

expanding the project's scope to address healthcare integrity broadly. The goal is to train 

seniors to be better healthcare consumers and to increase the reports of healthcare error, 

fraud, waste, and abuse. The objectives are to: 1) enhance its statewide coverage by 

continuing to revise its volunteer structure by expanding the current regional system aligned 

with the CWAG nine districts to a county-based lead volunteer representative system and 

redesign the project's volunteer positions to reflect four distinct levels of involvement; 2) 

improve beneficiary education and problem resolution by continuing to create training 

materials and publications for use by volunteers and project partners that teach seniors to be 

better healthcare consumers by identifying and reporting healthcare integrity problems; 3) 

foster national visibility by continuing to share materials and experiences with the National 

Consumer Protection Technical Resource Center; 4) improve the efficiency and effectiveness 

of the project through increased complaint referrals by encouraging seniors to report 

suspected cases of healthcare fraud more broadly; and 5) continue to focus educational and 

training opportunities for isolated and hard-to-reach populations. Expected outcomes 

include: 1) an increase in the number of elderly individuals educated; 2) an increase in the 

number of inquiries to the project and rate of inquiry resolution; and an 3) increase in 

Medicare, Medicaid, and other healthcare savings. Products will include: project reports, as 

required; evaluation results; two websites, written articles for publication; data on 

performance outcomes; and presentations at national conferences. 




Project Title: Senior Medicare Patrol for Wyoming 



Wyoming Senior Citizens, Inc. 

106 West Adams Avenue 

PO Box BD 

Riverton, WY 82501 

Contact: 

Charlie Simineo 

Tel. (307) 856-6880 

Email: execdir@wyoming.com 


Fiscal 

Year 

Funding 

Amounts 









Total $360,000 


This is a three-year grant to the Wyoming Senior Citizens, Inc. to conduct a Senior Medicare 

Patrol (SMP) project to serve isolated and rural, low income, disabled, and Native Americans 

on the Wind River Indian Reservation. The goal of this project is to educate those persons 

who will benefit from Medicare fraud and abuse information, Medicare Modernization Act and 

Medicare Part D changes. The objectives are to: 1) train SMP volunteers; 2) educate 

beneficiaries and general public about Medicare fraud; 3) test beneficiaries' knowledge 

through feedback survey to determine if information presented was beneficial; 4) track data 

on number, types and results of referrals; 5) recruit and maintain retired professionals, as well 

as one bilingual volunteer; educate seniors who do not visit senior centers; 6) establish at 

least one coalition partner in each county; and 7) update educational materials. Expected 

outcomes are: 1) increased volunteer knowledge; 2) increased awareness of the SMP 

program in the general population; 3) increased identification of problems on health care bills 

and explanation of benefits; 4) increased efficiency in tracking data; and 5) increased savings 

of dollars in the Medicare program. Products from the project will include brochures, posters, 

bookmarks, health care journals, playing cards, hand sanitizers, band-aid kits and other 

educational materials and reports as required, including evaluation results. 


National Consumer Protection Technical Resource Center 

AoA held a new grant competition in FY2010 to support a cooperative agreement to operate 

the National Consumer Protection Technical Resource Center. The Center provides training, 

technical assistance, and promotional activities in support of the SMP program formerly 

known as the Senior Medicare Patrol. SMP projects train and mobilize senior volunteers to 

provide education to Medicare and Medicaid beneficiaries and the public in their communities 

targeting health care fraud. The program authorized under the 1996 Health Insurance 

Portability & Accountability Act, Titles II and IV of the Older Americans Act, as amended is 

operated by 54 grantees in all states, the District of Columbia, Puerto Rico, the US Virgin 

Islands, and Guam. The goal of the Center is to provide professional expertise and technical 

support, and serve as an accessible and responsive central source of information, in order to 

maximize the effectiveness of the 54 Senior Medicare Patrol (SMP) projects in healthcare 

integrity outreach and education. 

Additional information about SMP including a link to the Resource Center may be found on 

the AoA website: 

http://www.aoa.gov/AoARoot/AoA Programs/Elder Rights/SMP/index.aspx 


Program: National Consumer Protection Technical Assistance Center 


Project Title: National Consumer Protection Technical Resource Center 

Project Period: 09/30/2003 – 08/31/2010 


Hawkeye Valley Area Agency on Aging 

2101 Kimball Avenue, Suite 320 

Waterloo, IA 50702 

Contact: 

Ginny Paulson 

Tel. (877) 808-2468 

Email: gpaulson@hvaaa.org 

AoA Project Officer: Barbara Lewis 

Fiscal 

Year 

Funding 

Amounts 









Total $3,106,782 


The grantee, Hawkeye Valley Area Agency on Aging, supports this three year National 

Consumer Protection Technical Resource Center project, in collaboration with Health 

Benefits ABCs, and related governmental and consumer protection groups. The goals of the 

project are to: provide training and technical assistance to Senior Medicare Patrol (SMP) 

projects to increase their knowledge and ability to meet their mission, and increase national 

visibility and integration of the SMP Projects into the aging and fraud prevention network. 

The objectives are to: 1) advance the Administration on Aging's strategic priorities for the 

SMP Program; 2) improve beneficiary education and inquiry resolution for health care fraud; 

3) improve the efficiency and quality of the SMP program; 4) help SMPs target training and 

education to hard-to-reach populations; 5) increase SMP program visibility; and 6) enhance 

SMP program consistency. The expected outcomes of this project are to: 1) achieve 

mastery of SMART FACTS as a reporting and program management tool; 2) increase the 

number and appropriateness of SMP referrals to resolution entities; 3) standardize volunteer 

certification program implementation plan and curriculum development; 4) increase the 

number of nationwide entities who are familiar with the SMP program; 5) increase training 

and education tools available to SMPs for reaching hard-to-reach populations; 6) increase 

tools available to SMPs to promote a unified fraud prevention, detection, and reporting 

message; 7) increase SMP satisfaction with and utilization of such tools; 8) increase SMP 

staff knowledge of health care fraud and consumer protection issues; and 9) the project 

evaluation using Re-AIM will reflect positive results in SMP ability to achieve their program 

mission consistently and with quality. The products of this project are: a web-site, 

newsletters, e-digest, updated operations manuals, volunteer certification implementation 

plan and curriculum, needs assessment, fact sheets, Public Service Announcements, webconferences, 

evaluation, and abstracts for national conference presentations. 


Program: National Consumer Protection Technical Resource Center 

Grant Number: 90NP0001 

Project Title: The National Consumer Protection Technical Resource Center; The 

Center of Service and Information for Senior Medicare Patrol 



Hawkeye Valley Area Agency on Aging Inc 

Consumer Protection Division 

2101 Kimball Avenue Suite 320 


Contact: 

Ginny Paulson 

Tel. (877) 808-2468 

Email: gpaulson@hvaaa.org 

AoA Project Officer: Barbara Lewis 


Year Amount 


Total $860,000 


Hawkeye Valley Area Agency on Aging (HVAAA), with the assistance of subject matter 

experts, proposes to continue operating the National Consumer Protection Technical 

Resource Center (The Center), as it has since its inception in 2003. The project goal is to 

provide centralized training, support and technical assistance to Senior Medicare Patrol 

(SMP) projects and forge national visibility and consistency for the SMP program. The 

objectives are to: 1) facilitate SMP sharing of knowledge, experience, and successful 

practices; 2). develop national, standardized SMP outreach and volunteer training and 

management products; 3) support the management and referral of beneficiary complaints 

received by SMPs; 4) provide SMPs and the public with accessible, accurate, relevant and 

timely information about health care fraud and consumer protection for older adults; 5) 

represent the SMP program to the national media and national level partners; and 6) facilitate 

national consistency through accurate reporting in SMART FACTS. The expected outcome 

is: The Center’s activities will prove vital in assisting SMPs in meeting AoA’s five SMP 

strategic objectives and achieving the SMP program mission of empowering seniors to 

prevent healthcare fraud. Products that will be delivered include: 1) mentor program to 

support SMP project directors; 2) SMART FACTS training, support and system 

improvements; 3) website for consumers and SMPs, including a Resources for SMPs portal; 

4) presentations to a national audience via conferences and webinars; 5) webinar trainings 

on topics needed to expand the knowledge and competencies; 6) standardized SMP 

volunteer training, risk management, and program manuals; and 7) reports of SMP feedback, 

achieved through evaluation, needs assessments and stakeholder meetings. 


Resource Centers for Older Indians, Alaska Natives, and Native Hawaiians 

The AoA has supported at least one Resource Center for Older Indians, Alaska Natives, and 

Native Hawaiians since 1994 which serve as the focal points for developing and sharing 

technical information and expertise for Native American organizations, Native American 

communities, educational institutions, and professionals working with elders in culturally 

competent health care, community-based long-term care, and related services. AoA has also 

funded support for development of its Older American Act (OAA) Title VI Grants for Native 

Americans grants to tribal organizations under its National Minority Aging Organizations 

(NMAO) Technical Assistance Centers Program. 

For more information about the resource centers and Title IV grants go to the AoA website: 

http://www.aoa.gov/AoARoot/AoA Programs/HCLTC/Native Americans/index.aspx 


Program: National Resource Centers on Older Indians, 

Alaska Natives and Native Hawaiians 

Grant Number: 90OI00001 

Project Title: National Resource Centers on Older Indians, Alaska Natives 

and Native Hawaiians 



University of Alaska - Anchorage 

3211 Providence Drive 

Anchorage, AK 99508 

Contact: 

George Charles 

Tel. (907) 786-1065 

Email: afgpc1@uaa.alaska.edu 

AoA Project Officer: :Cecilia Aldridge 

Fiscal 

Year 

Funding 

Amounts 









Total $461,232 


The National Resource Center on Older Indians, Alaska Natives and Native Hawaiians 

(Center) is focused on Alaska Native elder issues. They goal is to increase elder mental 

health through collaboration by: 1) decreasing the absence of respect; 2) safety and 

wellness (elder mistreatment); 3) coordinating organizational service delivery; and 4) 

expanding elder knowledge of available services/programs for Alaska Native elders. The 

project focuses on building core tools to eliminate fractionalization of elders' services, 

including the creation of a network of providers. The Center coordinates services of all 

organizations in the state of Alaska providing services to Native Alaska elders and compiles 

this information into a directory. The Center facilitates cross organizational meetings and 

partnerships via audio conferencing and information dissemination in two partner meetings 

and one statewide meeting. All gathered information is provided to the elders, their councils 

and organizations via meeting presentations and Blackboard dialogs. Products being 

developed are educational tools (basic health education materials such as health literacy, 

over/under/conflicting/of medication), demonstrate implementation models (best promising 

and emerging practices to be replicated with cultural adjustments), and continued program 

implementation into future years. It is anticipated that these products will help prevent 

various geriatric medical maladies to decrease health disparity of elders. 




Grant Number: 90OI0002 

Project Title: Ha Kupuna: National Resource Center for Native Hawaiian Elders 



University of Hawaii 

Sakamaki Hall D-200 

2530 Dole Street 


Contact: 

Colette Brown 

Tel. (808) 956-9081 

Email: cbrowne@hawaii.edu 

AoA Project Officer: Cecilia Aldridge 

Fiscal 

Year 

Funding 

Amounts 









Total $291.510 


The Ha Kupuna - a Resource Center for Native Hawaiian Elders (Center) was established in 

2006. The goal of this Center is to develop and disseminate knowledge on health and longterm 

care in order to increase and improve the delivery of services to Native Hawaiian elders 

and their caregivers. Objectives are to: 1) sustain their core organizational structure; 2) 

develop a national knowledge base; 3) provide technical assistance and training to Title VI 

organizations; 4) improve the capability of organizations in using a qualitative methodology; 

5) record the stories of elders; and 6) broadly disseminate information. Over the course of 

the project this Center's activities will include: 1) six completed reports; 2) two completed 

manuscripts; 3) six presentations at national and local meetings/conventions; 4) two meetings 

for advisory council members; 5) coordination with the two other funded Native American 

Resource Centers; 6) updated Website; 7) focus groups with caregivers caring for Native 

Hawaiian elders; 8) focus groups with members of the Association of Hawaii Civic Clubs 

(representing Native Hawaiian elders); and 9) expand to Native Hawaiian elders in California. 

The Center's outcome measures include increases in knowledge, skills, and/or capacity 

among members of their Advisory Council, Title VI service providers, and other providers 

working with Native Hawaiian elders within the state of Hawaii and the California aging 

network. 





Project Title: University of North Dakota National Resource Center on Native 

American Aging 



University of North Dakota 

Center for Rural Health 

School of Medicine 

501 North Columbia Road 

Grand Forks, ND 58202-9037 

Contact: 

Twyla Baker-Demaray 

Tel. 800-896-7628 

Email: Twyla.baker@med.und.edu 


Fiscal 

Year 

Funding 

Amounts 









Total $797,138 


The goal of the National Resource Center on Native American Aging (Center) is to provide 

culturally sensitive community training and technical assistance to Native elder providers and 

information and resources for elders and Native elder-focused organizations. The major 

objectives are to: 1) pilot test the WELL-Balanced senior exercise curriculum developed in 

2008-2009; 2) advance Native elder caregiving resources; 3) provide research training; 4) 

research elder abuse codes; 5) offer training seminars based on the national data file; and 6) 

continue current dissemination efforts. The anticipated measurable outcomes for the project 

include: 1) improved means of communication and resources for Native American elders; 2) 

provision of a culturally sensitive program to help older Native people stay active and healthy; 

3) identification of health and social status for future long-term planning; 4) increased 

knowledge of resources for Native American elders; 5) increased awareness of elder abuse, 

codes, and resources; 6) provision of training and updates on Center programs and needs 

assessment data; and 7) improvement and dissemination of Center resources, including 

presentations, journal articles, fact sheets, curriculums, and toolkits. 





Project Title: University of North Dakota National Resource Center on Native 

American Aging 



University of North Dakota 

School of Medicine 

501 North Columbia Road 

Grand Forks, ND 58202 

Contact: 

Twyla Baker-Demaray 

Tel. 800-896-7628 

Email: Twyla.baker@med.und.edu 


Fiscal 

Year 

Funding 

Amounts 









Total $1,133,183 


The National Resource Center on Native American Aging, located at the Center for Rural 

Health, University of North Dakota School of Medicine and Health Sciences has been of 

service to American Indian, Alaska Native, and Native Hawaiians since 1994. The Center's 

efforts have concentrated on the goal of "raising the quality of life for Native elders to the 

highest possible level" through technical assistance, training, conducting needs assessments, 

and research. To reach that goal, the Center is pursuing three continuing objectives: 1) to 

continue to assist an increasing number of the 561 federally recognized tribes and tribal 

organizations with determining the needs of their elders; 2) to continue to provide feedback 

for those who have conducted the Identifying Our Needs: A Survey of Elders and to improve 

that feedback by providing information regarding best practices, exemplary projects and 

promising innovations; and 3) to continue to conduct training for service providers working 

with elders on a regular basis at national and regional conferences and monthly seminars 

hosted by, but not limited to, the Administration on Aging Regional Offices, Kauffman and 

Associates and the National Indian Council on Aging. 


Health Disparities among Minority Elderly - Technical Assistance Centers 

The Administration on Aging has long supported national organizations representing minority 

elderly populations to assist the network of State and area agencies on aging in targeting 

social services to their constituencies. In recent years the focus of support has been to 

address health disparities unique to minority groups. During FY2010 continuation awards 

were made to three organizations first funded in FY2009 and a new award in FY2010 

targeting older Indians. 

The FY2010 funding opportunity was open to National Indian Tribal Organizations to support 

a center to develop culturally appropriate evidence based training materials addressing 

behavioral issues that family caregivers of American Indian/Alaska Native (AI/AN) elders with 

dementia can use themselves or in conjunction with service providers. The long term goal 

sought is to reduce or eliminate health disparities by increasing access to culturally 

competent and linguistically appropriate front line strategies that specifically target the Native 

American population. It is anticipated that increasing access to practical, nontraditional, 

community-based interventions for overcoming barriers to due to language and low literacy 

as well as other barriers directly related to cultural diversity will assist older individuals and 

their family caregivers to better manage care. 

Additional information about the National Minority Aging Organization Technical Assistance 

Centers may be found on the AoA website: 

http://www.aoa.gov/AoARoot/AoA Programs/Elder Rights/Minority Aging/index.aspx 


Program: Health Disparities among Minority Elders-Technical Assistance Centers 

Grant Number: 90HD0001 

Project Title: Bienestar (Well Being) 



Asociacion Nacional Pro Personas Mayores 

234 E. Colorado Blvd, Suite 300 

Pasadena, CA 91197 

Contact: 

Carmela G. Lacayo 

Tel. (626) 564-1988 

Email: anppm@aol.com 

AoA Project Officer: Diane A. Freeman 

Fiscal 

Year 

Funding 

Amounts 









Total $438,314 


The Asociacion Nacional Pro Personas Mayores (ANPPM) is implementing existing and new 

approaches to chronic disease self management programs that will enable Hispanic elder 

persons to develop the confidence and motivation they need to manage the challenges of 

living with a chronic disease and to enhance the ability of the Hispanic community and the 

Aging Network to provide health promotion and disease prevention approaches that are 

culturally competent for managing major diseases confronting this population by establishing 

a national network of peer volunteers trained to introduce Hispanic elders to the practical 

skills and knowledge they need to understand their chronic disease and enhance their own 

well being. Major objectives include: 1) preventing chronic disease through integrated health 

education models focused on major diseases and their risk factors; 2) replicating, through the 

ANPPM’s national network, the use of Chronic Disease Self Management Programs 

(CDMSP) designed by Stanford University’s Patient Education Center for use with Spanish 

speaking older Hispanics; and 3) improving the health status of older Hispanics and all racial 

and ethnic minority older persons through more effective outreach methods designed to 

eliminate health disparities among older minority populations. The project is targeting older 

adults of Hispanic descent, including hard-to-reach, vulnerable and limited English-speaking. 

Anticipated Outcomes are: 1) older Hispanics will have increased access to practical skills 

and knowledge they need to under stand how to manage their chronic diseases for their own 

well being; 2) a national network of bilingual, community based peer counselors trained to 

serve older Hispanics through CDSMP programs; and 3) a cadre of selected SCSEP 

participants trained and mobilized in support of the network of CDSMP older adults. Products 

include CDSMP modules designed, pilot tested and targeted to low literacy older Hispanics 

and a web based CDSMP information site in Spanish. 




Project Title: National Minority Aging Organizations Technical Assistance 

Centers 

Project Period: 08/01/2009 – 07/312012 


National Caucus and Center on Black Aging 

1220 L. Street, NW Suite 800 


Contact: 

Karyne D. Jones 

Tel. (202) 637-8400 

Email: Kjones@ncba-aged.org 

AoA Project Officer: Diane Freeman 

Fiscal 

Year 

Funding 

Amounts 









Total $438,314 


The Administration on Aging entered into a cooperative agreement with the National Caucus 

and Center on the Black Aged, Inc. (NCBA) to operate Project SURGE, (Seniors Unite with 

Resources to Get Empowered: A Community Health Action and Advocacy Training Program). 

NCBA’s goal is to advance knowledge and increase the effectiveness of future efforts to 

eliminate health disparities among African American elders. NCBA enlists its affiliates to 

reach its target population. Volunteers help older African Americans adopt healthier lifestyles 

using a trusted, decentralized, community-based approach through a network which includes 

senior housing communities, churches and senior centers. Staff participated in Chronic 

Disease Self Management (CDSM) training at Stanford University during early fall 2009. 

Volunteers will be trained as master trainers to promote the use of CDSM skills among older 

people. Initially, the project will be conducted in Baltimore, MD; Buffalo, NY; Oklahoma City, 

OK and with the Medical University at South Carolina in Charleston, SC. 




Project Title: Technical Assistance Center for Asian Pacific Islander Seniors 

Project Period: 08/01/2009 – 07/312012 


National Asian Pacific Center on Aging 

1511 Third Avenue, Suite 914 

Seattle, WA 98101 

Contact: 

Alula Jimenez 

Tel. (206) 838-8166 

Email: Alula@napca.org. 

AoA Project Officer: Diane Freeman 

Fiscal 

Year 

Funding 

Amounts 









Total $704,632 


The National Asian Pacific Center on Aging (NAPCA) Technical Assistance Center has as its 

goal improvement of health care outcomes and quality of life and the reduction of health care 

costs for API seniors. NAPCA reaches the 26 API subgroups across the Nation through its 

health, employment and advocacy programs. NAPCA’s Title V SCSEP has sites in nine 

cities, including Boston, Chicago, Houston, Los Angeles, Orange County (CA), New York, 

Philadelphia, San Francisco and Seattle. With this network as a foundation upon which to 

build, NAPCA is in a unique position to reach API seniors through the interagency, 

collaborative effort on expanding the availability of diabetes self-management training 

programs. Training in Chronic Disease Self Management (CDSM) skills will be taken by staff 

in order to promote the use of these skills in a culturally competent way among older Asian 

American and Pacific Islanders. Additionally, NAPCA maintains a toll free multilingual 

hotline. 




Project Title: National Minority Aging Organization Technical Assistance Center 

Development of Dementia Care Resources for American Indians 



National Indian Council on Aging 

10501 Montgomery Blvd NE, Suite 210 



Year Amount 


Contact: 

Randella Bluehouse J. Bluehouse 

Tel. (505) 292-2001 

Email: rbluehouse@nicoa.org 



Total $127,323 

The National Indian Council on Aging, in collaboration with the University of Oklahoma Health 

Sciences Center, will conduct under this Center activities to increase the quality of life for 

American Indian/Alaska Native caregivers caring for elders afflicted with dementia. Project 

objectives are to: 1) partner with caregiving intervention experts; 2) identify an evidencebased 

program to assist with caregiver coping skills; 3) modify the program to be culturally 

appropriate for American Indian/Alaska Native caregivers; 4) test the modified program at two 

American Indian/Alaska Native sites; 5) conduct measurable evaluations; and 6) utilize the 

outcomes to develop a user-friendly new product for American Indian/Alaska Native 

caregivers to help improve their quality of life through better understanding and knowledge of 

coping skills to address dementia behaviors. The expected outcomes are: 1) caregivers who 

have learned to think about their situation more objectively; 2) caregivers who have gained 

the knowledge, skills, and attitudes to better manage dementia behaviors and their own 

stress levels; and 3) carry out the caregiving role more effectively. Products from this project 

will include: a modified evidence-based program that retains its original fidelity but is effective 

with American Indian/Alaska Native caregivers; training tools; and a caregiver manual. 


National Education and Resource Center on Women and Retirement 

Planning 

Among the priorities of the Assistant Secretary for Aging (ASA) is helping to empower older people 

and their families to make informed decisions about, and be able to easily access existing health and 

long-term care options. On March 11, 2009, President Barack Obama issued an Executive Order 

establishing White House Council on Women and Girls and charged the Council to “Ensure that each 

(Federal) agency is working directly to improve the economic status of women and girls.” Accordingly, 

the Administration on Aging (AoA) conducted a grant competition in FY2010 through which it awarded 

a cooperative agreement to continue support for a National Education and Resource Center on 

Women and Retirement Planning. 

The Center was first established in 1998, partners with the AoA to assist the National Network on 

Aging to facilitate access to the principles of basic financial and retirement planning for low income 

women, women of color and other hard to reach women, including those with limited English speaking 

proficiency. It was created because studies show that 75% of Baby Boomers are not prepared for 

retirement. Many will retire or be forced to retire unexpectedly. In fact, 4 in 10 people retire due to 

poor health, caregiving responsibilities or job loss. The impact of these factors is more pronounced 

among women. Over the next two decades 40 million women will reach retirement age. 2 Median 

Social Security income for women is 70% of that for men. While women retirees are likely to earn 

only half the average pension benefits a man earns, only about 45% of women versus 54% of men 

even participate in pension plans 

Information about the National Education and Resource Center on Women and Retirement Planning 

can be found on the AoA website: 

http://www.aoa.gov/AoARoot/AoA Programs/Elder Rights/Women in Retirement/index.asp 

x 

2 What Every Woman Needs to Know about Retirement, Hounsell, Cindy and Lewis, Jeffrey, 

WISER publication, p.1 


Program: National Educationa and Resource Center 

on Women and Retirement Planning 

Grant Number: 90PN0001 

Project Title: National Education and Resource Center on Women and Retirement 

Planning 



Women's Institute for a Secure Retirement 

1146 19th Street, NW - Suite 700 

Washington , DC 20036-0734 


Year Amount 


Contact: 

Cindy Hounsell 

Tel. (202) 393-5452 

Email: wiserwomen@aol.com 

AoA Project Officer: Dianne Freeman 


Total $245,763 

The Women’s Institute for a Secure Retirement (WISER) was awarded a three year cooperative 

agreement to operate the National Education and Resource Center on Women and Retirement 

Planning (The Center). The Center serves as a national clearinghouse for tools and information on 

retirement planning and related financial education materials. WISER’s mission is to inform women 

about the issues that affect their long-term financial security and to stress the importance of women 

taking an active role in planning for their retirement. WISER is partnering with AoA to assist in 

responding to the President’s charge to the White House Council on Women and Girls (the Council) to 

“ensure that each (Federal) agency is working directly to improve the economic status of women and 

girls;” and affirming the priorities of the Assistant Secretary for Aging (ASA) to empower older people 

and their families to make informed decisions about, and be able to easily access existing health and 

long-term care options. The Center objectives include supporting the integration of the concepts of 

basic financial and retirement planning into the structure of Older Americans Act (OAA) Programs and 

to improve women’s access to basic financial and retirement planning and other educational tools that 

promote financial literacy by coordinating with national professional, membership, regional, statewide 

and local organizations. This collaborative effort promotes the piloting and adapting of “user-friendly” 

financial and retirement planning information models. The Center is also developing strategies to 

better educate employers, especially small business employers, about ways to design or adapt 

retirement programs to the women in their workforces. Center activities incorporate the latest 

technology to generate and disseminate knowledge in appropriately packaged forms that can assist 

women, especially low-income women, women of color, and women with limited English-speaking 

proficiency, to build their capacity to plan for and to exercise the most prudent options for their 

economic security in later life. 


Eldercare Locator 

AoA has been funding the Eldercare Locator (the Locator) since 1991. The Locator assists 

older adults, their families and caregivers find their way through the maze of services for 

seniors by identifying trustworthy local support resources. The goal is to provide users with 

the information and resources they need that will help older persons live independently and 

safely in their homes and communities for as long as possible. Since its inception, over 2 

million older adults, caregivers, professionals and others have used the nationally recognized 

toll-free number, 1-800-677- to find resources for older adults in any U.S. community. 

In FY2010 AoA held a competition for a new cooperative agreement to operate the Locator. 

The Locator was initially designed as a directory assistance service with live agents helping 

older adults and their families and caregivers find their way through the maze of services for 

seniors by linking to a trustworthy network of national, State, Tribal and community 

organizations and services through a nationally recognized toll-free number. In 2008, the 

Locator transitioned to a call-routing system to expand the capacity of the service and to 

connect callers directly to the resource at the local level. The new program announcement 

sought to advance the Locator by both returning to a call center and adding a number of 

enhancements that would support older adults and caregivers getting the information they 

need. 

The website for the Eldercare Locator is here: 

http://www.eldercare.gov/Eldercare.NET/Public/Resources/Main.aspx 


Program: Eldercare Locator Program 


Project Title: Elercare Locator National Call Center to Assist Older Adults and 

Caregivers 




1730 Rhode Island Avenue, NW, Suite 1200 



Year Amount 


Contact: 

Helen Eltzeroth 

Tel. (202) 872-0888 


AoA Project Officer: Sherri Clark 


Total $1,449,854 

The goal of the National Association of Area Agencies on Aging's project is to advance the 

development and evolution of the Eldercare Locator to be the key aging portal so that older 

persons and their caregivers can get the information, guidance and assistance they need to 

help them remain independent in their homes and communities for as long as possible. This 

goal will be achieved through the following objectives: 1) Successfully implement a personcentered 

state-of-the-art Call Center; 2) Expand the Call Center reach and resources through 

collaborations and content expertise that meet the needs of older adults and caregivers; and 

3) Expand outreach, education and marketing efforts to include new technologies and 

approaches that recognize and respond to the needs and interests of the diverse population 

of adults and caregivers. 


National Aging Information and Referral Support Center 

The U.S. Administration on Aging (AoA) has been funding the National Aging Information and 

Referral Support Center (the Support Center) since 1991. The Support Center was 

established to assist the Aging Network enhance the quality and professionalism of their 

information and assistance systems. The Support Center provides training, technical 

assistance, product development and consultation to State Units on Aging and Area 

Agencies on Aging, Information and Referral and Assistance (I&R/A) programs, and Aging 

and Disability Resource Centers. Since inception the Support Center has played an 

important role in the evolution and advancement of aging I&R/A. 

More information about the activities of the Support Center may be found on this website: 

http://www.nasua.org/issues/tech assist resources/national aging ir support ctr/index.html 


Program: National Aging Information & Referral Support Center 

Grant Number: 90IR0001 

Project Title: National Aging Information and Referral Support Center 



National Association of State United for Aging and Disabilities 

1201 15th Street, NW Suite 350 



Year Amount 


Contact: 

John Thompson 

Tel. (202) 898-2578 128 

Email: jthompson@nasua.org 

AoA Project Officer: Sherri Clark 

Total $300,000 


The National Association of States United for Aging and Disabilities will direct the National 

Aging Information and Referral (I&R/A) Support Center in collaboration with several partners. 

The project’s goal is to operate a premier national resource center for aging I&R/A issues, 

training and certification exam preparation, technical assistance, and to represent the 

interests of I&R/A to national organizations and federal agencies serving seniors and persons 

with disabilities. The objectives are: 1) to provide training to the aging and disability network; 

2) to provide technical assistance and consultation services to the aging and disability 

network; 3) to coordinate I&R/A activities related to diversity, taxonomy, certification, 

management information system and information technology, and training at a national level; 

and 4) to establish an evaluation and quality assurance program to assess the Support 

Center and I&R/A professionals’ performances routinely. The expected outcomes are: 1) 

increased number of Certified Information and Referral Specialist in Aging trained 

professionals prepared to take the exam; 2) higher utilization rate and satisfaction of aging 

I&R/A professionals receiving online, telephonic, and onsite technical assistance and 

consultation services; and 3) improved awareness of national organizations and federal 

agencies representing aging and individuals with disabilities about the vital role of I&R/A in 

Aging and Disability Resource Center (ADRC) operations, nursing home diversions and 

transition planning, and helping consumers secure long-term services and supports. 


National Alzheimer’s Call Center 

AoA held a competition In FY2010 to award a three year grant under a cooperative 

agreement for continued support of the National Alzheimer’s Call Center (the Center). The 

Center is a national information and counseling service for persons with Alzheimer’s disease, 

their family members, and informal caregivers. The National Alzheimer’s Call Center is 

available to people in all States, 24 hours a day, 7 days a week, 365 days a year to provide 

expert advice, care consultation, and information and referrals at the national and local levels 

regarding Alzheimer’s disease. Trained professional customer service staff and masters 

degree social workers are available at all times. The Call Center is accessible by telephone, 

website or e-mail at no cost to the caller. In the 12-month period ending July 31, 2009, the 

National Alzheimer’s Call Center handled over 250,000 calls through its national and local 

partners, and its on-line message board community recorded over 4.8 million page views, 

with nearly 75,000 individual postings. 

Services focus on consumers, not professionals. Information provided may include 

basic information on caregiving; handling legal issues; resources for long-distance caregiving; 

and tips for working with the medical community. Local community-based organizations are 

directly involved to ensure local, on-the-ground capacity to respond to emergencies and ongoing 

needs of Alzheimer’s patients, their families, and informal caregivers. The Call Center 

has multilingual capacity and responds to inquiries in at least 140 languages through its own 

bilingual staff and with the use of a language interpretation service. 


Program: Alzheimer's National Call Center 

Grant Number: 90AC0001 

Project Title: Alzheimer's Association Call Center 



Alzheimer's Disease and Related Disorders Association 

225 N. Michigan Ave Suite 1700 

Chicago, IL 60601-7633 


Year Amount 


Contact: 

Beth A. Kallmyer, Senior Director Constitutent Services 

Tel. (312) 335-5708 

Email: beth.kallmyer@alz.org 


Total $987,000 


The Alzheimer’s Disease and Related Disorders Association under a cooperative agreement 

with the Administration on Aging operates an Alzheimer’s National Call Center (Contact 

Center) for individuals with Alzheimer’s disease and their caregivers. The goal of the project 

is to improve the quality of life for people impacted by Alzheimer’s through an integrated 

network of Information Service Specialists and Care Consultants who provide personalized 

information, support, care consultation and crisis intervention via a single toll free number, 

email and website, 24 hours a day, 365 days a year. The project approach is to provide 

access for callers to services through the toll free number in a partnership between the 

Contact Center and our chapter network. The objectives are: 1) provide personalized 

responses to every consumer; 2) collaborate with the aging network to increase awareness of 

the Contact Center; 3) promote increased utilization of the Contact Center by minority, 

underserved and limited English speaking populations as well as by the general public; 4) 

maintain and expand online resources; and 5) evaluate the call center through quantitative 

and qualitative methods. The expected outcomes for the project include: 1) users of the 

Contact Center will have an increased understanding of Alzheimer’s disease as well as an 

improved ability to manage the effects of the disease; 2) the Contact Center will exceed 

industry performance standards; 3) callers will report being satisfied with the quality of 

services provided; 4) awareness and usage of the Contact Center by the general public and 

particularly by minority and limited English speaking populations will increase; and 5) 

awareness of the Association’s services among the aging network will increase. 


National Aging Civic Engagement Technical Center 

The Administration on Aging (AoA) held a grant competition in FY2010 to fund, through a 

cooperative agreement, a National Aging Civic Engagement Technical Center (Center). The 

award of a three year grant continues AoA implementation of provisions in the 2002 Older 

Americans Act (OAA) Amendments addressing volunteer and civic engagement activity. 

Volunteers have been essential to OAA programs throughout their history. The recent 

convergence of a number of forces, including growing budget constraints on program 

spending and research, point to civic engagement as important to healthy aging, support 

tapping into the social capital potential of volunteers. 

The Center will support the volunteer needs of the Older Americans Act Aging Network, 

including its 56 State and 629 Area Agencies on Aging, 244 Tribal and Native and 20,000 

community organizations. The Center will use and build upon knowledge of current and past 

volunteer and civic engagement activities to develop and test new strategies for effective, 

replicable and sustainable volunteer activities to increase the capacity of the National Aging 

Network and to address community needs. 

Information about AoA’s Civic Engagement involvement can be found on its website: 

http://www.aoa.gov/AoARoot/AoA Programs/Special Projects/Civic Engagement/index.aspx 


Program: National Aging Civic Engagement Center 

Grant Number: 90CC0081 

Project Title: National Aging Civic Engagement Technical Center 




1730 Rhode Island Ave., NW Suite 1200 

Washington, DC 20036-3109 

Contact: 

Helen Elzeroth 

Tel. No. (202) 872-0888 


AoA Project Officer: Marla I. Bush 

Fiscal 

Year 

Funding 

Amounts 









Total $969,210 


The National Association of Area Agencies on Aging will create a National Aging Civic 

Engagement Technical Assistance Center (the Center). The Center will help AoA and the 

Aging Network use volunteers more effectively, especially Boomers; develop AoAs’ and the 

Aging Network’s leadership in civic engagement; and expand the Aging Network’s use of 

volunteers. The Center, working together with the AARP Foundation, the National 

Association of State Units on Aging and Disabilities and Senior Service America 

Incorporated, will 1) conduct a systematic inquiry on civic engagement; 2) recommend an 

Action Plan in civic engagement for AoA and the Aging Network; 3) develop a national 

communication and outreach strategy; 4) provide training and technical assistance; 5) identify 

effective practices, develop and promote models; and 6) create a continuous quality 

improvement strategy. The measurable outcomes is change in the Network’s ability to meet 

needs and preferences of volunteers. Products include anAction Plan; volunteer 

management toolkits; model practice fact sheets; conferences; website widgets and a final 

report. 


Office of the Deputy Assistant Secretary for Aging 

The Office of the Deputy Assistant Secretary for Aging supports the Assistant Secretary on 

Aging in providing executive direction, leadership and guidance for programs and operations. 

It also coordinates the operations of the Regional Support Centers and through it responds to 

the needs of older individuals following a Presidential disaster declaration, oversees disaster 

assistance and reimbursement activities described in Section 310, Title III of the Older 

Americans Act. In FY2010 three grants were awarded for disaster assistance under this 

authority. 


Disaster Assistance for State Units on Aging and Tribal Organizations 

Grants awarded under this program are to provide disaster reimbursement and assistance 

funds to those State Units on Aging (SUAs) and tribal organizations who are currently 

receiving a grant under Title VI of the Older Americans Act (OAA), as amended. These funds 

only become available when the President declares a National Disaster and may only be 

used in those areas designated in the Disaster Declaration issued by the President of the 

United States. The statutory authority for AoA grants under this program announcement is 

contained in Title III of the Older Americans Act (OAA). 

Funds typically requested are for the following Title III types of gap-filling services: outreach, 

information and assistance, counseling, case management, advocacy on behalf of older 

persons unable or reluctant to speak for themselves, and staff overtime. Funds may be used 

for additional food, supplies, extra home delivered meals, home clean up and safety, 

emergency medications, transportation and other such immediate needs. Disaster 

Assistance are limited to 2% of funds appropriated each year for Title IV discretionary 

awards. In FY2010 Title IV funding was slightly above $19 million. Funds are held in reserve 

until the last month of the fiscal year to meet the needs of States when faced with national 

disasters that cannot be anticipated and if not needed are used to fund other priorities under 

Title IV. 

Information about Disaster Assistance grants may be found on the AoA website section for 

Emergency Preparedness and Response: 

http://www.aoa.gov/AoARoot/Preparedness/index.aspx 


Program: Disaster Assistance 

Grant Number: 90DA2857 

Project Title: Case Management/Contract Services for Access to Elders Affected 

by the 2010 Flood of RI. Services to include: assistance 




74 West Rd. 



Year Amount 


Contact: 

Corinne C. Russo 

Tel. (401) 462-0565 


AoA Project Officer: Irma Tetzloff 


Total $30,000 

Following a Presidential declared disaster on March 29, 2010, the Rhode Island Department 

of Elderly Affairs received a disaster assistance award of $30,000 to assist the elderly during 

and after extensive flooding caused by eight inches of rain in a 36 hour period. This storm 

affected 20,000 of the State’s residents and was particularly difficult for the elderly population. 

Many had to evacuate to shelters and others who were cut off from all services and 

assistance for several days after the flooding. Many lost all of their food, clothes, bedding 

with extensive furniture damage. There were considerable home damages with ruined 

appliances and furnaces, debris cleanup and mold/mildew issues, and other residential and 

care management problems. These funds were needed to help defray the cost of extensive 

“gap-filling” services crucial for keeping seniors safe and healthy. The State staff and 

services providers provided immediate case management, nutritional, transportation and 

other emergency supportive services. The case management efforts to help seniors apply for 

FEMA assistance, SBA loans, file insurance claims and resolved post-flood issues continued 

over a period of several weeks with case managers working long hours, seven days a week. 




Project Title: Comanche Disaster Assistance Grant 

Project Period: 09/30/2010 – /9/31/2011 


Comanche Indian Tribe of Oklahoma 

Post Office Box 908 

Lawton, OK 73502 

Contact: 

Micael Burgess 

Tel. (580) 492-3386 

Email: michaelb@comanchenation.com 


Fiscal 

Year 

Funding 

Amounts 









Total $15,366 


A Disaster Assistance grant was awarded to the Comanche Nation for much needed financial 

assistance in coping with last winter’s severe storms that occurred January-March 2010. A 

late January storm affected all 63,000 square miles of the Reservation. Many Tribal 

members had to “crawl” out of there homes only to find massive tree damage, extensive 

power outages and inaccessible roads. All services, including Title VI funded home-delivered 

meals and in-home services, were completely closed down for an extended period. The 

height of storm occurred during the January 28 through February 7, 2010. The long-term 

power outages, no heat, and difficulty in obtaining water and food, made this a trying winter 

for the Comanche Tribe. Many had to be evacuated and heat was provided by generators for 

an extended period of time. The requested AoA funds are being used to reimburse the 

Comanche Nation for expenses incurred in assisting the 322 Tribal elderly during this 

prolonged and severe winter storm period. 




Project Title: 2010 Tennessee Flood Disaster Assistance Program 



Tennessee Commission on Aging and Disability, 




Year Amount 


Contact: 


Tel. (615) 741-2056 



Total $39,130 


The Tennessee Commission on Aging and Disability was awarded $39,130 for disaster 

assistance following a severe storm which extended from April 30 through May 2, 2010. The 

western counties of Tennessee received unprecedented rainfall accompanied by tornados, 

severe wind storms and high winds resulting in extensive flooding throughout 52 of the 

State’s 95 counties. On May 4, 2010, the President issued a declaration which was amended 

to include a total of 42 counties home to over 400,000 of the State’s elderly. The heavy 

flooding in the Nashville area caused severe and extensive damages to homes accompanied 

by the loss of household possessions. It took several days to reach some of the isolated 

rural low-income elderly because of road damage and power outages. Part of the funds 

reimbursed the SUA for “gap-filling” services incurred as the flooding escalated. These 

services included case management, nutrition, transportation and other emergency 

supportive services needs. After the disaster declaration, 896 individuals over age 60 

registered for assistance from FEMA with two-thirds of those cases still in process. The 

Commission worked closely with the State’s Emergency Management Agency and the 

National Organizations Active in Disaster (VOADs). Area Agencies received many requests 

for assistance from seniors who have not used OAA services previously. These funds were 

given to five Area Agencies (AAAs) responsible for managing programs in the designated 

counties and cover a portion of the costs for case management, food replacement, clean-up 

efforts and other supportive care. 


Congressional Identified Projects 

While the Administration on Aging (AoA) awards the majority of its project grants through 

proposal competitions focusing on specific topics authorized in the Older Americans Act 

(OAA) it also supported projects, commonly known as “earmarks,” whose purpose and 

organizational recipient historically were identified in Congressional appropriation committee 

reports accompanying AoA annual appropriations. Beginning in FY2008 Congress changed 

the method of identifying member sponsored projects by naming them directly in 

appropriation language. AoA for its part before FY2008 allowed Congressional Identified 

projects to designate project periods longer than 12 months if the specified funding amount 

permitted. Since FY2008 Congressional Directed Projects, are limited at the time of award to 

12 months but are permitted a limited no-cost extension permitted when requested near the 

end of the grant. To the extent possible, AoA staff monitoring of these grants are assigned to 

AoA staff working in the Central and Regional Support Offices most closely corresponding to 

their programmatic purpose and expertise. 

In FY2010 twenty-two (22) Congressional Directed Project projects were funded. 

Approximately half of these projects support programs assisting older adults to continue living 

independently in their communities. 


Program: Congressional Identified Projects 

Grant Number: 90MA0048 

Project Title: Promoting a National Resource Center on Family Caregiving 



Family Caregiver Alliance 

National Center on Caregiving 

180 Montgomery Street Suite 1100 

San Francisco, CA 94104-4240 

Contact: 

Kathleen Kelly 

Tel. (415) 434-3388 

Email: kkelly@caregiver.org 



Year Amount 


Total $500,000 


The Family Caregiver Alliance (FCA) supports this one year project to promote a national 

resource center on family caregiving. The goal of the project is to increase the visibility and 

capacity of FCA's National Center on Caregiving as a nationally-recognized and trusted 

resource on policies and programs related to family caregiving, serving families, public 

agencies and private organizations. The objectives are to: 1) advance research and policy 

analysis to refine the state-of-the-art in caregiving; 2) establish a reliable information center 

for family caregivers nationwide, providing telephone assistance and an online database of 

state-by-state information; and 3) provide a clearinghouse of information, support, and 

training to program administrators, policymakers, service providers, and others who work with 

and on behalf of family caregivers. The expected outcomes are: 1) increased awareness, 

knowledge and advocacy on the part of policymakers, program administrators and other 

advocates about proven or promising policies for supporting family caregivers; 2) caregiver 

access to resources and support services in state and local communities; and enhanced 

knowledge and skills of professionals working in caregiver support programs, and 3) other 

stakeholders, through easy access to information about policies and competencies related to 

caregiver support. Products include papers on policies to support economic security for 

family caregivers, up-to-date state profiles with background characteristics and information 

about caregiving policies, fact sheets on key policy indicators, an updated online database of 

state resources for family caregivers, and an online clearinghouse of legislation, policy 

reports, campaigns and initiatives focused on family caregiving. 




Project Title: Pathways to Positive Aging 



City of Fremont 

Human Services 

3300 Capitol Avenue 

Fremont, CA 94537-5006 

Contact: 

Suzanne Shenfil 

Tel. (510) 574-2051 

Email: sshenfil@fremont.gov 



Year Amount 


Total $150,000 


The City of Freemont’s Human Services Department in collaboration with the Tri-City Elder 

Coalition of government and community organizations will build upon best practice model 

programs to continue development of Pathways to Positive Aging which finds creative 

solutions to find resources to support older adults as they successfully age in place. The goal 

of this program is to build a community where seniors can understand, choose, and access 

culturally enriched, affordable services and opportunities that enhance their quality of life. 

The objectives of this project are to: 1) sustain and refine community engagement and 

training opportunities that build community capacity involving volunteers; 2) continue 

implementation of a strategic plan that effectively links elders to services and opportunities, 

improves public perception of the aging process, and supports the coordination of community 

organizations and services. Among expected outcomes of Pathways to Positive Aging are: 

1) more frail seniors aging in place in their community; 2) grater integration of services 

between community and providers; 3) more efficient use of resources and reduction of 

duplication of effort; and 4) increases in social networks reducing isolation of seniors. 

Products will include replicable volunteer training models, evaluation results, articles and data 

for publications on community organizing methods for presentations at state and national 

conferences. 




Project Title: Regional Senior Services Collaboration 



City of Long Beach 

Health and Human Services 

2525 Grand Avenue 

Long Beach, CA 90815-1765 

Contact: 

Theresa J. Marino 

Tel. (562) 570-4011 

Email: theresa.marino@longbeach.gov 



Year Amount 


Total $100,000 


The City of Long Beach Department of Health and Human Services will develop a one-year 

project that will encompass three months of planning strategies and activities to recruit 

stakeholders from each of the five cities in the 37th Congressional District and nine months 

for implementing the Regional Senior Services Collaboration (RSSC). The goal of the RSSC 

is to develop and engage an alliance of senior services and stakeholder organizations from 

the local aging networks, public, private, community and faith-based sectors in the region that 

will plan, assess, advocate and work together to develop strategies and identify resources for 

meeting the growing needs of the burgeoning senior population in the 37th District. 

Objectives include: 1) establishing a Planning Task Force of 12 -15 voluntary members from 

the region to assist in the 3-month planning activities, including establishing meeting 

procedures to facilitate productive meetings; 2) assessing and collecting data to address 

regional senior needs; 3) conducting monthly meetings with a committed membership of 20 

25 agencies; 4) conducting provider and community education regarding senior issues; 5) 

evaluating the effectiveness of the collaboration. The expected outcomes of the collaboration 

will be to provide capacity to build, connect and strengthen interagency and inter-jurisdictional 

relationships among 20 or more agencies for addressing challenging issues, needs and gaps 

in senior services in the region. The RSSC will provide awareness and educational 

opportunities through guest speakers and develop products, such as articles, informational 

pieces and a regional senior resources directory. Evaluation of the project will assess the 

benefits, outcomes, lessons learned and best practices. 


Program: Congressional Directed Projects 


Project Title: Rapid Response Expert Team 



County of Ventura 

Human Services Agency 

855 Partridge Drive 

Ventura, CA 93003 

Contact: 

Jeff Landis 

Tel. (805) 477-5444 

Email: jeff.landis@ventura.org 

AoA Project Officer: Stephanie Whittier Eliason 


Year Amount 


Total $654,000 


The Ventura County human Services Agency will integrate medical and mental health experts 

into the existing Rapid Response multi-disciplinary team to reduce or eliminate protective 

issues of dependent adults and elders 65 and over who have difficult to resolve complex 

medical and mental health risk indicators and are served by Ventura County Adult Protective 

Services. The Rapid Response multidisciplinary teams is a collaboration and partnership 

with the District Attorney, the Area Agency on Aging, Tri-Counties Regional Center, the Long 

Term Care Ombudsman program, the Public Administrator Public Guardian, the Superior 

Court and the Departments of Behavioral Health and Public Health within the Health Care 

Agency. Project objectives are to: 1) utilize the Ventura County Risk Curve; 2) conduct inhome 

assessments by the medical and mental health experts; 3) increase the medical/mental 

health resources to the Rapid Response Team; and 4) disseminate the project’s design, 

findings and results. Expected outcomes are: 1) establish a standardized approach to risk 

assessment, intervention and outcomes; 2) reduce or eliminate the protective issue with 

improvement in the client’s health and safety; and 3) demonstrate the positive results of 

increased resources to a multi-disciplinary team through a series of pre-mid and post survey 

testing. Produces will include a final report on the design, development and efficacy of the 

Risk Curve and the promising practices of integrating medical and mental health experts into 

a social service oriented multi-disciplinary team. 




Project Title: "Safe at Home" Fall Prevention and Home Safety Interventions for 

Older Adults 



Rebuilding Together, Inc. 

Safe at Home 

1899 L Street, NW Suite 1000 


Contact: 

Gregory C. Secord 

Tel. (202) 384-6781 

Email: gsecord@RebuildingTogether.org 



Year Amount 


Total $349,275 


Rebuilding Together, Inc. (RT), under the “Safe-at-Home” project is continuing to build upon 

its collaborative partnerships to enable more low-income elderly to live in a safe and 

accessible home environment by strengthening its partnerships with the Aging Network and 

the American Occupational Therapy Association (AOTA). The AOTA and the National 

Association of Area Agencies (N4A) have joined forces to complete 24 demonstration 

projects followed by an independent evaluation of the outcomes and effectiveness of the 

projects. This evaluation will establish a foundation for establishing “evidenced-based” 

results for continuous improvements in the program. In addition, Rebuilding Together will 

continue to improve a web-based home safety assessment tool and increase widespread 

distribution. Four regional training workshops will be conducted as well. RT is a nationwide 

non-profit organization with 200 plus affiliate chapters calls upon community resources and 

volunteers, including professional builders, to assist with home modifications and critical 

repairs for low-income, elderly individuals. Volunteers work along side Certified-Aging-in- 

Place Specialist (CAPS) so that participation in these home modification projects provides 

valuable hands-on learning for individuals who want to live throughout their lives in their own 

homes and communities. 




Project Title: Congressional Mandates 

Project Period 07/01/2010 - 06/30/2011 


Stetson University 

1041 61st Street South 

Gulfport, FL 33707-3246 


Year Amount 


Contact: 

Rebecca C. Morgan 

Tel. (727) 562-7872 

Email: morgan@law.stetson.edu 

AoA Project Officer: Doris Summey 


Total $100,000 

Stetson University’s College of Law, by and through the Center for Excellence in Elder Law, 

branded under the banner, "ACCESS and Justice for all," will continue its Financial Scam & 

Fraud Elder Awareness Project" for a second year (2010-2011). The goal is to develop a 

project designed to inform and educate elder individuals about financial scams and frauds. 

The objectives are: 1) to decrease the occurrence of and minimize the potential for financial 

scam and fraud victimization among elder individuals and (2) to produce a sustainable and 

replicable project that can be duplicated and implemented throughout the State of Florida, as 

well as in other individual states nationwide. The expected outcomes are: 1) an increase in 

awareness among elder individuals about financial scams and frauds; 2) creation of 

education and informational written, digital and resource materials and services providing and 

promoting financial scam and fraud awareness; and 3) production of a replication handbook 

providing a "how-to-model" for project implementation and duplication. Products will include 

speeches and presentations, brochures and handouts, webpage platforms and interfaces, 

non-legal technical assistance advice, reference databases and resource guides, a 

replication handbook to assist with project duplication and implementation. 




Project Title: Georgia Naturally Occurring Retirement Communities (NORC) 

Initiative 



Jewish Federation of Greater Atlanta 

1440 Spring Street, NW 



Year Amount 


Contact: 

Deborah A. Kahan 

Tel. (404) 870-1624 

Email: dkahan@jfga.org 



Total $100,000 

The Jewish Federation of Greater Atlanta (JFGA) was the "umbrella" organization of the 

NORC Initiative in Georgia until 2009 and continues to be a prominent coalition partner while 

transitioning responsibility for project management to Jewish Family and Career Services. 

JFGA continues to provide technical assistance and support to the NORC, including overall 

marketing, fund raising and reporting. The Georgia NORC Initiative’s primary goal has been 

to help older residents stay at home safely, maximizing their capacity for independence, 

activity and integration with their community for as long as possible by preventing premature 

institutionalization and avoidable hospitalization. The approach is to work with seniors to 

identify the unmet needs in their communities and to develop innovative programs and 

services to meet these needs. The Georgia NORC Initiative’s objectives include: 1) reducing 

risk factors associated with premature institutional care; 2) building the community’s capacity 

to support seniors in the aging in place process; 3) greater coordination of services between 

agencies; 4) enlisting additional partner agencies, particularly non-traditional partners; 5) 

disseminating information about the Georgia NORC Initiative; and 6) building the 

sustainability of the Georgia NORC Initiative. The expected outcomes of this Initiative are: 1) 

reducing social isolation; 2) increasing home safety; 3) increasing knowledge of and access 

to community resources; and 4) improving seniors¿ ability to manage chronic disease and/or 

health challenges. The products from this Initiative are: a final report, including evaluation 

results; enhanced program services in the NORC sites; and articles for publication. 







Catholic Charities of Hawaii 

1822 Keeaumoku Street 



Year Amount 


Contact: 

Diane M. Terada 

Tel. (808) 527-4702 

Email: diane.terada@catholiccharitieshawaii.org 



Total $400,000 

Catholic Charities Hawai`i (CCH) will implement Project HOPE (Helping Others Promoting 

Employment) to assist elders who are aging in place. The goal of this one year 

demonstration project is to help frail elders maintain independent living by providing a 

network of quality and affordable community-based services, including a component of 

employment opportunities for individuals with developmental disabilities and/or mental 

retardation (DD/MR). The project will increase affordable service options for elders and help 

CCH develop infrastructure and processes to continue the project beyond the funded period 

through a sustainable fee structure. The objectives are to: 1) conduct market research and 

create a business plan to focus on the consumer demands of low to moderate income frail 

elders and their family caregivers; 2) provide case management, transportation and chore 

services for frail elders at affordable and sustainable rates; 3) establish system infrastructure 

to maintain private and Medicaid billing; 4) train individuals with DD/MR to provide chore 

services for frail elders through supported employment; and 5) evaluate the economic 

sustainability of the model. The expected outcomes are: 1) at risk frail elderly clients will 

maintain independent living for six months; 2) family caregivers will experience reduced 

stress and increased positive attitude toward caregiving; and 3) individuals with DD/MR will 

be employed for at least three months upon completion of initial training and job placement. 

The products include a final report, including evaluation results and training modules for 

individuals with DD/MR to provide chore and elders/caregivers who employ DD/MR chore 

workers. 


Program: Congressional Projects 


Project Title: Research on the Needs Facing Gay, Lesbian, Bi-sexual and 

Trangender Elders Living with HIV 



SAGE Center on Halsted 

3656 N Halsted St 

Chicago, IL 60613-5974 


Year Amount 


Contact: 

Serena B. Worthington 

Tel. (773) 472-6469 

Email: sworthington@centeronhalsted.org 



Total $475,000 

SAGE (Services and Advocacy for Gay, Lesbian, Bisexual and Transgender Elders) Center 

on Halsted (COH) supports this one-year research, training and advocacy project in 

collaboration with AIDS Community Research Initiative of America (ACRIA), Founding SAGE 

(FS) and related senior service and HIV/AIDS groups. The goal of this project is to improve 

programs and services for lesbian, gay, bisexual and transgender (LGBT) older adults. The 

approach is to partner with established agencies to conduct research and training and to 

enhance service provision. The objectives of this project are to: 1) survey 200 individuals 

regarding HIV risk behavior and health; 2) improve the quality of HIV prevention education by 

creating a prevention film with LGBT older adults; 3) train and deploy SAGE patrons as 

constituent advocates and educators; 4) train providers in culturally competent care; 5) 

increase gender and racial/ethnic diversity of program participants 6) improve data collection 

and program evaluation; 7) increase computer use by individuals with low vision and; 8) 

disseminate results. The expected outcomes are: 1) LGBT older adults, HIV/AIDS service 

providers, senior service providers, COH staff and the larger community will have a better 

understanding of LGBT aging and older adults; 2) HIV; the HIV prevention film will be used as 

an outreach and education tool, constituent advocates will provide training and conduct 

advocacy on LGBT aging issues; and 3) pre and post test training of senior services 

providers will reflect positive results from training. The products are a final report; an HIV 

prevention film; data on HIV positive and at- risk older adults; enhanced computer resources, 

a member database; and conference abstracts and presentations. 







MOSAIC 

2708 N. 11th St 

Garden City, KS 67846-2714 


Year Amount 


Contact: 

Debbie A. Reynolds 

Tel. (620) 275-9180 

Email: debbie.reynolds@mosaicinfo.org 



Total $350,000 

Mosaic in Garden City, will implement Legacy Senior Services, in collaboration with the 

Southwest Kansas Area Agency on Aging, the Alzheimer's Association of Central and 

Western Kansas, the Senior Center of Finney County, and the Garden City Area Alzheimer's 

Support Group for Caregivers. The goal of the project is to provide quality, meaningful 

services in an integrated setting for seniors with intellectual and developmental disabilities 

(I/DD) and seniors with Alzheimer's. The objectives are: 1) to develop an Americans with 

Disabilities Act (ADA)-accessible facility in which to operate the Legacy Senior Services 

program; 2) to extend the amount of time seniors are able to remain in the community and 

delay entry into full-time professional nursing care facilities; and 3) to maintain or improve 

seniors' independent functioning levels through meaningful activities. The expected 

outcomes of the Legacy Senior Services program are: 1) a fully-functional and accessible 

facility for program activities that meets all required licensing and ADA standards; 2) 

decreased need for costly nursing home placements; 3) new data about efficacy of a new 

model of service delivery for seniors with I/DD and Alzheimer's; 4) maintained or improved 

independent functional levels of seniors in the Legacy Senior Services program; increased 

satisfaction of seniors with I/DD and Alzheimer's; and 5) increased satisfaction of caregivers 

of seniors with I/DD and Alzheimer's. The products from this project are a final report with 

evaluation of the program; data on any changes in independent functioning levels and health 

status of program participants; data on I/DD and Alzheimer's training; quarterly newsletters; 

and articles for publication. 



Grant Number 90MA0034 

Project Title: Family Caregiver Access Network 



Jewish Family Service of Metropolitan Detroit 

6555 W. Maple Rd. 

West Bloomfield, MI 48322 


Year Amount 


Contact: 

Perry Ohren 

Tel. (248) 592-2302 

Email: pohren@jfsdetroit.org 



Total $200,000 

The Family Caregiver Access Network (FCAN) is a non-sectarian project of Jewish Family 

Services of Metropolitan Detroit (JFS). JFS, the lead agency, will partner with the Brown 

Jewish Community Adult Day Care Program (operated jointly by Jewish Senior Life and JVS), 

and other organizations, to support family caregivers of adults. The goal of the project is to 

reduce caregiver burden, and improve the lives of caregivers and those for whom they are 

caring and reduce premature institutionalization. The objectives are to 1) address barriers 

that lead to underutilization of existing caregiver support services; 2) increase caregiver selfidentification; 

3) connect caregivers with needed resources and services; 4) implement a 

more seamless and coordinated service delivery system of local agencies and supports; 5) 

improve the lives of care recipients as their caregivers experience reduced stress; 6) diminish 

early institutionalization of care recipients and develop a replicable model to be shared with 

other agencies. Outcomes include caregivers will: 1) experience reduced burden and stress; 

2) be healthier; 3) feel more support in their caregiving role; and 4) have more confidence in 

their role as a caregiver. Pre and post tests will measure caregiver burden and statistics will 

be kept on institutionalization rates. Project implementation was modified based on lessons 

learned in fiscal year 2009. Project deliverables include a final report; evaluation results, 

dissemination plan; and updated website. 




Project Title: JFCS CHOOSE INDEPENDENCE - Caregiver Support 



Jewish Family and Children’s Service of Minneapolis 

13100 Wayzata Bldv., Suite 400 

Minneapolis, MN 55305 


Year Amount 


Contact: 

Mari Forbush 

Tel. (952) 542-4812 

Email: mforbush@jfcspmls.org 



Total $250,000 

Jewish Family and Children’s Service (JFCS) of Minneapolis CHOOSE INDEPENDENCE 

Caregiver Support (CICS) project will provide outreach, education, needs assessment, and 

ongoing support to the growing number of Hennepin County, Minnesota caregivers. CICS 

leverages the existing partnerships to offer an effective, integrated and holistic community 

support system. The goal of CICS is to create an effective, replicable model that reaches 

500 of the estimated 4,400 area caregivers. All seniors and caregivers in the cities of St. 

Louis Park, Hopkins, and surrounding communities will have access to services. The CICS 

objectives are: 1) provide education and outreach to help people identify as caregivers, raise 

awareness of the impact of care giving, and gain an understanding of the resources available 

to support both seniors’ and caregivers’ independence and quality of life; 2) increase quality 

caregiver assessments; and 3) increase service coordination for seniors and their caregivers. 

The project will realize one main outcome that caregivers in West Hennepin County will have 

a greater ability to sustain their caregiving. Products will include articles in local newspapers 

and agency newsletter; website; and an annual report. 




Project Title: RSVP Home Companion Respite Care Program 



Nevada Rural Counties RSVP Program 

2621 Northgate Lane, Suite 6 



Year Amount 


Contact: 

anice Ayres 

Tel. Tel. (775) 687-4680 ex. 2 

Email: branded@rsvp.carson-city.nv.us 

AoA Project Officer: Dennis Dudley 


Total $195,000 

The Nevada Rural Counties Retired and Senior Volunteer Program (RSVP), is a selfsponsored 

non-profit 501 (c) (3) Corporation serving Nevada’s seniors for over 36 years. The 

RSVP Home Companion Respite Care Program provides respite to caregivers of both family 

members and professionals who provide 24/7 care to hundreds of senior Nevadans. The 

program assists caregivers with family members suffering from Attention-Deficit Disorder, 

Post Stroke, Dementia, Parkinson's, Multiple Sclerosis, Alzheimer's, cancer, heart problems, 

head injuries and seizure disorders. This assistance is key in lowering the stress levels of 

caregivers, by giving them a break to allow a healthier existence and longer life expectancy, 

and preventing the institutionalization of their loved ones. It is a low cost/free respite care 

service and no one is turned away because of inability to pay. RSVP volunteer members 

provide the caregiver with essential breaks for up to four hours a day to engage in enjoyable 

activities and attend to their own needs, helping reduce the stress and fatigue as a result of 

their tireless and unselfish efforts. It also provides the one being cared for with “experienced” 

companionship. Volunteer members are well prepared with extensive pre -service and inservice 

training. The program serves 15 of the 17 counties in Nevada: Carson City, Churchill, 

Douglas, Elko, Esmeralda, Eureka, Humboldt, Lander, Lincoln, Lyon, Mineral, Nye, Pershing, 

Storey and White Pine. 




Project Title: United Jewish Communities of MetroWest New Jersey - Lifelong 

Involvement for Vital Elders Independent Aging Initiative 



United Jewish Communities of MetroWest New Jersey 

Planning and Allocations 

901 Route 10 East 

Whippany, NJ 07981-1105 

Contact: 

Karen Alexander 

Tel. (973) 929-3193 

Email: kalexander@ujcnj.org 



Year Amount 


Total $100,000 


United Jewish Communities (UJC) of MetroWest New Jersey, in partnership with civic 

groups, and other providers, will implement a one-year Aging in Place demonstration project 

focused on community organization, service coordination and provision to older adults. Using 

techniques piloted in Parsippany and refined in Caldwell, UJC will replicate the Lifelong 

Involvement for Vital Elders (LIVE) program in Verona, NJ, which has a population of 13,533 

and approximately 5,000 residents age 60+. Forty-six percent (46%) of the households 

include an older person. The project will support a range of social, physical, spiritual, 

recreational, health, wellness, and housing needs for older adults by increasing access to 

information, resources, supportive services, and civic engagement opportunities. Key 

objectives include: 1) establishing local site coordinators, incorporating LIVE into the service 

delivery system; 2) assessing community assets and needs; 3) engaging a diverse range of 

partners; and 4) facilitating delivery of collaborative services to older adults. An "elderfriendly" 

community will be created to meet the needs of its aging members by harnessing the 

skills and expertise of diverse organizations and involving older adults. Effective techniques 

and strategies will be shared with service providers, funding organizations and colleagues 

within the broader aging network. Project outcomes include: 1) a reduction in isolation for 

older adults through expanded social, recreational and educational opportunities; 2) greater 

ability of older adults to maintain independence through increased access to information, 

resources, and supportive services; and 3) facilitation of new community collaborations that 

engage older residents and thereby enhance support for older adults. 




Project Title: Aging in Place in Northern New Jersey 



UJA Federation of Northern New Jersey 

75 Johnson Ave. 

Teaneck, NJ 07652-1429 


Year Amount 


Contact: 

Alan P. Sweifach 

Tel. (201) 820-3931 

Email: alans@ujannj.org 



Total $200,000 

UJA Federation of Northern New Jersey (UJA) will continue to conduct a demonstration 

project utilizing methods developed for programs and services in Naturally Occurring 

Retirement Communities (NORCs) in collaboration with multiple agency partners including: 

two family service agencies, two residential facilities for Older Adults, and a community 

center. The goal of this program is to meet the needs of older adults who wish to remain 

independent in their own homes by providing a range of locally-based (in or near-home) 

health and supportive services that improve and maintain their physical well being, provide 

opportunities for socialization, and enhance their general quality of life. The objectives are: 

1) to provide comprehensive in-home and/or community-based care management and 

nursing assessments as well as expanded care management and community nursing 

services; 2) to provide community-based cultural, educational, social and recreational 

programs in order to ease social isolation and enrich the lives of older adults; 3) to form a 

NORCs Council involving Older Adults in the planning and implementation of services and 

programs; 4) to develop collaborations with community and governmental agencies; 5) to 

evaluate the effectiveness of the program; and 6) to share findings with the broader 

Community. The expected outcomes are: 1) Increased access to social and medical 

services, and 2) reduced social isolation. The products from this project are a final report 

including evaluation results, participation in a national evaluative study, and articles in the 

print and electronic media. 




Project Title: Critical Innovations in Aging in Place 



Jewish Family Service Agency of Central New Jersey, Inc 

655 Westfield Ave. 

Elizabeth, NJ 07208 


Year Amount 


Contact: 

Tom Beck 

Tel. (908) 352-8375 

Email: TBeck@jfscentralnj.com 



Total $300,000 

Jewish Family Service Agency of Central New Jersey (JFS) will build on its NORC LINKS 

program to include resident involvement and partnerships with local groups, business, and 

private agencies. The overall goal of this Naturally Occurring Retirement Community 

(NORC) program is to develop a model of supportive services to maintain and/or improve the 

quality of life of older adults and allow them to age safely with dignity and quality of life in their 

communities while creating efficiencies and cost savings in service delivery. Activities are 

supported to include all residents in order to build community and community based services 

that will maintain the residency and contributions of older adults. Work will emphasize the 

strengths and capacities of individuals and their communities while acknowledging individual 

needs to be addressed. The objectives for this program include: 1) to increase access to 

services; 2) to increase knowledge of healthy lifestyles; 3) to improve socialization and 

community building; and 4) to expand the model through program replication. Products from 

this project will include a final report that includes evaluation results and data on 

effectiveness of all aspects of the program. 




Project Title: Home Sweet Home Aging in Place Project 



Jewish Family Service of Somerset Hunterdon and Warren County 

Senior Services 

150 A West High Street 

Somerville, NJ 08876-1854 

Contact: 

Jerry Starr 

Tel. (908) 725-7799 

Email: Admin@JewishFamilySvc.Org 



Year Amount 


Total $225,000 


The grantee, Jewish Family Service of Somerset, Hunterdon and Warren Counties (JFS) is 

conducting a one year aging in place project called Home Sweet Home (HSH) with the 

collaboration of the Somerset County Office on Aging, the Shimon and Sara Birnbaum 

Jewish Community Center, Somerset County Community Visiting Nurse Association and 

Brookside Gardens Apartment Complex. The project goal is to help seniors age in place in 

their own homes by providing a coordinated array of social services including comprehensive 

care management, counseling, community linkage, socialization activities and community 

organizing activities and community education and use of community volunteers. Individual 

services offered by this project will be coordinated with other service providers in the area so 

that seniors in need of assistance can maximize their use of the entire social service network. 

The objectives are to: 1) conduct outreach to the community to find the seniors currently 

underserved and in need of assistance; 2) provide comprehensive bio-psychosocial 

assessments and care plans as needed to address individual needs and problems; 3) refer 

residents to established services/programs whenever possible to minimize duplication of 

effort; 4) develop socialization programs that enhance quality of life and reduce isolation and 

loneliness; 5) assess periodically functional status and quality of life factors, 6) evaluate 

effectiveness of the project; and 7) disseminate information to the larger community. 

Expected outcomes are that 80% of those enrolled in this project will report: 1) improved 

social support; 2) improved well being and self sufficiency; 3) reduction of depression; and 4) 

better understanding of community resources and improved access. The products from this 

project are a final report, results of a self care and wellness survey, articles for publication 

and posting on the agency website and presentations at conferences and meetings. 




Project Title: 2010 New York State Elder Abuse Summit Prevalence of Elder 

Abuse in New York: Next Steps 



Lifespan of Greater Rochester 

1900 South Clinton Avenue 

Rochester, NY 14618-5698 

Contact: 

Denise M. Shukoff 

Tel. No. (585) 244-8400 

Email: dshukoff@lifespan-roch.org 

AoA Project Officer: Stephanie Whittier Eliason 


Fiscal 

Year 

Funding 

Amounts 









Total $100,000 

Lifespan of Greater Rochester will plan and convene in Albany, New York, a second 

statewide Elder Abuse Summit in 2010. Highlights of the Summit will include: 1) release of 

the statewide Elder Abuse Prevalence Study – comparing results from the random phone 

survey and reported cases survey; and geographic/regional comparisons; 2) review of 

progress made on the 2004 priority recommendations and updating of the recommendations; 

3) regional breakout groups for the structured work group sessions. The conference will be 

conducted with experienced facilitators to lead and guide the Summit work groups and 

inspired by nationally recognized speakers during meals. This is nota conference – all 

participants are expected to fully participate in developing a new list of statewide priority 

recommendations to take action against elder mistreatment and neglect, and to develop 

implementation plans for each recommendation. It is an invitation only event with support 

given to enable full participation by those identified experts in the field. The first statewide 

Elder Abuse Summit was held in 2004 and modeled after the 2001 National Summit. The 

first Summit launched the creation of the New York State Coalition on Elder Abuse, a 

multidisciplinary collaborative venture, involving individuals, private organizations and public 

agencies representing a geographic and professional cross section of our state. A final 

report of the conference will be distributed to all members of the coalition and elder abuse 

organizations in other States. 




Project Title: Self Sufficiency for Senior Citizens in New York City 



NORC Supportive Services Center, Inc 

NYC-HOPS 

321 8th Avenue 


Contact: 

Nat Yalowitz 

Tel. (917) 825-8395 

Email: nynorc-psss@rcn.com 



Year Amount 


Total $500,000 


This project supports development of the New York - Home Organized Personal Services 

program (NY-HOPS) which builds upon a successful project of 15 years duration at the 

Naturally Occurring Retirement Community (NORC) program at Penn South Co-op in New 

York City. NY-HOPS will use the Penn South HOPS program as a model and create at least 

ten new HOPS programs at other Naturally Occurring Retirement Communities (NORCs) in 

New York City. The project will offer needed health and social services to senior citizens 

from qualified providers under existing agreements with the NORC Supportive Services 

Center, including help with obtaining eyeglasses, hearing aids, home health aides and other 

needed services not covered for most seniors by other sources. Out of pocket expenses for 

these products can and do amount to hundreds and thousands of dollars annually. NY 

HOPS sites will be selected based on a Request for Proposals that will be circulated to over 

100 programs serving seniors. Program directors at new NY-HOPS selected sites will be 

trained and given technical assistance in developing their programs. 




Project Title: Needs Assessment of the Irish Aging in Queens,New York 



Gallagher Outreach Program, Inc. 

225 East 79 Street suite 13a/b 

New York, NY 10075-0823 


Year Amount 


Contact: 

Elaine M. Walsh 

Tel. (917) 327-5614 

Email: ew340@columbia.edu 

AoA Project Officer: Barry Klitsberg 


Total $200,000 

This project is conducting a needs assessment to identify the service needs of the Irish aging 

community in Queens, New York, especially those living alone, to inform service providers 

and community organizations about those needs and gaps in service provision and to 

establish a knowledge base that will promote culturally sensitive interventions for the targeted 

population. Project objectives are: 1) to obtain data on the characteristics and health, 

service needs, utilization and gaps, and availability and sufficiency of informal supports; and 

2) to inform formal and informal service providers of needs and of service gaps. As a result 

of this project there will be: 1) increased knowledge about the service needs and resources 

of older Irish Americans living in Queens; 2) development of culturally sensitive services by 

local agencies in the field of aging; and 3) the development of informal networks of residents 

who will become first responders to elderly Irish who are at risk. Products include a final 

report, a major conference for stakeholders reporting the results of the needs assessment 

and recommendations for intervention, widely distributed executive summaries, palm cards 

with hints for community residents and abstracts for national conferences. 




Project Title: Dementia Leadership Initiatives Program 



Westminster Village 

803 N. Wahneta St. 

Allentown, PA 18109-2491 


Year Amount 


Contact: 

Rachel B. Osborn 

Tel. (610) 691-4524 

Email: rosborn@presbyterianseniorliving.org 



Total $225,000 

Westminster Village, a Presbyterian Senior Living (PSL) community in the Lehigh Valley of 

Pennsylvania, will implement the Dementia Leadership Initiatives Program (The Program) to 

enhance medical diagnosis, treatment and care for those with Alzheimer’s disease and 

related Dementia (ADRD). It will offer individuals and families vital information, enable its 

long-term care facilities to provide for optimal outcomes of care, and enhance community 

outcomes by providing the “best of the best” in dementia education, diagnosis, treatment and 

care. The Program is designed to impact three principal audiences: 1) staff of PSL 

communities - to develop appropriate assessment tools, become trained practitioners of the 

most advanced methods of dementia care, and expand networks to support individuals and 

families living with this disease, especially the seniors served in four Lehigh Valley facilities; 

2) Residents and participants at PSL facilities - to enhance cognitive fitness and their 

knowledge base about dementia, enabling them to pursue activities and choices that will 

positively impact their overall health; and 3) Lehigh Valley general public - for free education 

in maintaining brain health, mitigating the impact of dementia on one’s self or loved ones, and 

accessing a full range of community resources. Some anticipated outcomes are: 1) up to 50 

of PSL staff members will be trained to sustain the Montessori method of dementia care; 2) 

facilities will provide appropriate screening and assessment; new admission and discharge 

criteria for secure units; behavioral and medical management; and stronger support for 

families and staff; 3) residents and participants with dementia will experience decreased use 

of psychotropic medications, have enhanced physical well-being and demonstrate greater 

social engagement with family members, staff and others; and 4) facilities will provide models 

of person-centered care vs. the medical model of care for those living with dementia, 

anticipating changing national accreditation standards. 




Project Title: Caregiver Connection Program 



Jewish Family Service of Salt Lake City 

1111 Brickyard Rd., Suite 109 



Year Amount 


Contact: 

Noami D. Lee 

Tel. (801) 350-1069 

Email: naomidlee@gmail.com 



Total $300,000 

The Jewish Family Service of Salt Lake City, UT supports the Caregiver Connection Program 

of Project EncourAge, a one-year elderly care and caregiver support project. The goal of the 

project is to positively affect the wellbeing of family caregivers and increase their ability to 

sustain their caregiving in positive way. The approach is to expand current services and to 

integrate psycho-social aspects of care. The objectives are: 1) expand the service delivery 

system; 2) encourage caregiver self-identification and awareness of supportive programming; 

3) increase caregiver acceptance of support options; 4) increase service utilization; 5) 

evaluate program impact and disseminate results; and 6) sustain the project. Four outcomes 

are expected, including 1) increased awareness among participants of support and respite 

services; 2) increased service utilization; 3) increased satisfaction; and 4) services are more 

effectively and efficiently coordinated. Products from this project will include an interim and 

final report, including evaluation results; a webpage dedicated to the program; and articles for 

publication. 


Organization Index 

Academic Institutions 

American Indian, Alaskan Native and Native Hawaiian 

Organizations 

Area Agencies on Aging 

Local Government and State and Local Organizations 

State Government Agencies and Units on Aging 

National Organizations 

Academic Institutions 

Alaska 

University of Alaska – Anchorage 428 

California 

University of California, San Francisco 104 

Colorado 

Colorado State University, Department of Psychology 105 

Delaware 

University of Delaware 277 

Florida 

Stetson University 357 

Georgia 

Southwester State University 93,94 

Hawaii 

University of Hawaii 429 

Massachusetts 

Boston College 195 

University of Massachusetts at Boston 283 

New Hampshire 

University of New Hampshire 31,65,83 

North Carolina 

University of North Carolina, Chapel Hill 114 

North Dakota 

University of North Dakota 430,431 

Minot State University 351,405 


Texas 

Teas A&M University 226 

University of Texas Health Science Center at San Antonio 119 

Utah 

University of Utah 45 

American Indian, Alaskan Native and Native Hawaiian Organizations 

Alaska 

Mt. Sanford Tribal Consortium 252 

New Mexico 

National Indian Council on Aging 436 

Oklahoma 

Comanche Tribe of Oklahoma 450 

Area Agencies on Aging 

Florida 

Area Agency on Aging of Pasco-Pinelles, Inc. 326,379 

Georgia 

Atlanta Regional Commission, Aging Services Division 255 

Iowa 

Hawkeye Valley Area Agency on Aging 333,386,425.426 

Illinois 

AgeOptions 331,384 

Indiana 

Indiana Association of Area Agencies on Aging 332,385 

Massachusetts 

Elder Services of the Merrimack Valley 339,392 

Minnesota 

Metropolitan Area Agency on Aging 285 

Missouri 

District III Area Agency on Aging 341,395 

Montana 

Missoula Aging Services 344,397 

New York 

New York City Department for the Aging 261 

Tennessee 

Upper Cumberland Development District 359,414 

Virginia 

Virginia Association of Area Agencies on Aging 363,419 


Local Government and State and Local Organizations 

Alaska 

Alaska Legal Services Corporation 291 

California 

California Health Advocates 321,373 

California Independent Living Council 

Catholic Charities of Stockton 253 

City of Fremont 454 

City of Long Beach 455 

The Los Angeles Gay and Lesbian Community Center 254 

Legal Services of Northern California 282,292 

County of Ventura, Human Services Agency 456 

District of Columbia 

Legal Counsel for the Elderly 294,325,377 

Georgia 

Atlanta Legal Aid Society 295 

Jewish Federation of Greater Atlanta 459 

Hawaii 

Catholic Charities of Hawai’i 460 

Illinois 

SAGE Center on Halsted 461 

Kansas 

MOSAIC 462 

Kentucky 

Louisville/Jefferson County Metro Government 335,388 

Louisiana 

eQ Health Solutions, Inc. 336 

Louisiana Health Care Review 389 

Maine 

Legal Services for the Elderly, Inc. 297 

Maryland 

Coordinating Center for Home and Community Care 256 

Massachusetts 

Boston Medical Center 257 

Legal Advocacy and Resource Center 298 

Michigan 

Center for Social Gerontology 313 

Elder Law of Michigan 284,314 

Jewish Family Service of Metropolitan Detroit 463 

Michigan Medicare/Medicaid Assistance Program, Inc. 340,393 

Minnesota 

Jewish Family and Children’s Service of Minneapolis 464 


Missouri 

Catholic Charities of Kansas City-St. Joseph, Inc 258 

Nebraska 

Legal Aid of Nebraska 300 

Nevada 

Nevada Rural Counties RSVP Program 465 

New Hampshire 

Easter Seals New Hampshire 259 

New Jersey 

United Jewish Communities of MetroWest New Jersey 466 

UJA Federation of Northern New Jersey 467 

Jewish Family Service Agency of Central New Jersey, Inc 468 

Jewish Family Service of Somerset Hunterdon and Warren County 469 

Jewish Family and Vocational Services of Middlesex County 348,401 

New Mexico 

Jewish Family Service of Greater Albuquerque 2 60 

New York 

Gallagher Outreach Program, Inc. 472 

Lifespan of Greater Rochester, Inc 470 

NORC Supportive Services Center, Inc 471 

South Brooklyn Legal Services 286 

Visiting Nurse Service of New York 262 


Legal Services of North Carolina 301 

Ohio 

Pro Seniors, Inc. 302,352,406 

Pennsylvania 

Center for the Rights and Interests of the Elderly 355,409 

Supportive Older Women’s Network 263 

Westminster Village 473 

Rhode Island 

Rhode Island Legal Services, Inc. 303 

South Dakota 

East River Legal Services Corporation 413 

Texas 

Better Business Bureau Educational Foundation 360,415 

Family Eldercare, Housing and Community Services 264 

Neighborhood Centers, Inc., 265 

Texas Legal Services, Inc. 287,305 

Utah 

Jewish Family Service of Salt Lake City 474 

Utah Legal Services, Inc. 306 


Vermont 

City of Montpelier 266 

Community of Vermont Elders 361,417 

Vermont Legal Aid, Inc. 307 

West Virginia 

West Virginia Legal Aid, Inc. 308 

Wisconsin 

Coalition of Wisconsin Aging Groups, Elder Law Center 366,422 

Wyoming 

Wyoming Senior Citizens, Inc 367,423 

State Government Agencies and Units on Aging 

Alabama 

Alabama Department of Senior Services 4,127,178,317,369 

Alaska 

Department of Health and Social Services 5,128,317,370 

Arizona 

Department of Health 198,199 

Department of Economic Security 6,53,129,228,319,371 

Arkansas 

Department of Health 130,199 

Department of Human Services 7,320,372 

California 

Department of Aging 131,200 

Health and Human Services Agency 54,74 

Independent Living Council 8 

Colorado 

Department of Health and Environment 201 

Department of Human Resources 9,55,75,132 

Department of Regulatory Agencies 322,374 

Connecticut 

Department of Social Services 10,56,76,106,133,202,323,375 

Delaware 

Department of Health and Social Services 11,134,237,293,324,376 


Office on Aging 12,57,107,135 

Florida 

Department of Elder Affairs 13,58,77,92,108,136,179,203,229 

Georgia 

Department of Human Services 14,109,137,180,230,327,380 

Guam 

Guam Department of Mental Health and Substance Abuse 15 

Department of Public Health and Social Services 328,380 


Hawaii 

Department Of Health 204 

Executive Office on Aging 16,138,181,329,382 

Idaho 

Department of Health and Welfare 139,204 

Commission on Aging 17,110,330,383 

Illinois 

Department of Public Health 206 

Department on Aging 18,59,78,140 

Indiana 

Family and Social Services Administration 19,79,141,182 

Iowa 

Department on Aging 20,60,207 

Kansas 

Department on Aging 21,142,238,334,386 

Kentucky 

Cabinet for Health and Family Services 22,95,143 

Louisiana 

Department of Health and Hospitals 239 

Governor’s Office of Elderly Affairs 144,296 

Maine 

Department of Health and Human Services 

, Office of Elder Services 3,6180,96,145,183,208,337,390 

Maryland 

Department on Aging 24,62,81,146,209,338,391 

Massachusetts 

Executive Office of Elderly Affairs 25,63,82,111,147,184,210,231 

Department of Mental Retardation 240 

Mississippi 

Department of Human Services 343,395 

Michigan 

Department of Community Health 26,64,97,148,211 

Minnesota 

Department of Human Services 149 

Minnesota Board on Aging 27,185,212,241,341,393 

Missouri 

Department of Health and Senior Services 112,151,299 

Montana 

Department of Public Health and Human Services 28,186 

Nebraska 

Department of Health and Human Services 29,152,242,345,398 

Nevada 

Department of Health and Human Services 30,153 

Office of the Nevada Attorney General 346,399 


New Hampshire 

Department of Health and Human Services 

Division of Public Health Services 154,347 

Bureau of Elderly and Adult Services 187,400 

New Jersey 

Department of Health and Senior Services 32,155,213 

New Mexico 

Department of Health 33,66,113,156,402 

New York 

State Office for the Aging 34,84,157,188,214,232,243,348,403 


Department of Health and Human Services 35,98,158,215,233 

Department of Insurance 350,404 

North Dakota 

Dakota Department of Human Services 36,67 

Ohio 

Department on Aging 37,99,159,216,234 

Oklahoma 

Department of Human Services 38,68,160,217,244 

Insurance Department 353,407 

Oregon 

Department of Human Service 39,69,115,161,189,218,354,408 

Pennsylvania 

Department of Aging 85,162,245 

Puerto Rico 

Department of Public Health 163 

Governor’s Office of Elderly Affairs 356,410 

Office of the Ombudsman for the Elderly 116 

Rhode Island 

Department of Elderly Affairs 40,86,357,411,449 

Department of Health 164 

South Carolina 

Lt. Governor’s Office on Aging 41,117,165,190,219,304,358,412 

South Dakota 

Department of Social Services 42 

Tennessee 

Commission on Aging and Disability 43,87,118,166,451 

Texas 

Department of Aging and Disability Services 44,88,167,191,220 

Utah 


Department of Human Services 100,120,247,416 

Vermont 


Department of Disabilities, Aging and Independent Living 46,70,121 


Virgin Islands 

Department of Human Services 362,418 

Virginia 

Department for the Aging 47,71,122,170,192 

Washington 

Department of Social and Health Services 48,123,171,248 

Office of the Insurance Commissioner, 364,420 

West Virginia 

Department of Health and Human Services 49.89,172 

Wisconsin 

Department of Health Services 50,72,101,102,124,173,193,221,247 

Wyoming 


National Organizations 

California 

Asociacion Nacional Pro Personas Mayores 433 

Family Caregiver Alliance 249,453 


AARP Foundation 365,421 

American Bar Association Fund for Justice and Education 310 

National Association of Area Agencies on Aging 270,440,446 

National Caucus and Center on Black Aging 378 

National Association of States United for Aging and Disabilities 270,442 

National Committee for the Prevention of Elder Abuse 276 

National Consumer Law Center 312 

National Consumer Voice for Quality Long-Term Care 279 

National Council on Aging 175,223,224,268 

National Hispanic Council on Aging 378 

National Senior Citizens Law Center 311 

Pension Rights Center 289 

Rebuilding Together, Inc. 457 

Women's Institute for a Secure Retirement 438 

Illinois 

Alzheimer’s Disease and Related Disorders Association 444 

National Adult Protective Services Association 275 

New York 

SAGE (formerly Senior Action in a Gay Environment) 273 

Washington 

National Asian-Pacific Center on Aging 435

Compendium of AoA FY 2010 Discretionary Grant Awards

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